Emotion-Focused Therapy for Complex Trauma: An Integrative Approach [2 ed.] 1433836521, 9781433836527

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This book is a breath of fresh air. It calls it like it is. The differential treatment model of what treatment for what disorder has had its day. The authors’ proposed process-based approach to treatment moves us forward to a promising new transdiagnostic, transtheoretical approach focused on evidence-based processes of change that fit the needs of a given client. This is the future. A must-read, wonderful contribution. — L E SL I E GRE ENBERG, P h D, D ISTINGU I SHED R ESEA R CH PR OFESSOR EMER I TUS OF P SYCH O LO GY, YO RK U NIVE RS ITY, YOR K, ON TA R I O, CA N A DA , A N D AUTHOR OF PATTERNS OF CHANGE A N D C H ANGI NG EMOTI ON WI TH EMOTI ON

Sandra C. Paivio and Antonio Pascual-Leone have written an accessible and invaluable second edition of their integrative treatment model, emotion-focused therapy for complex trauma (EFTT). This innovative model is especially important as an evidence-based treatment of complex trauma of relatively short duration and with clearly delineated strategies and markers. Moreover, it has a flexibility of application and can be adapted for use with other treatment models depending on the needs of the client. —CH RISTINE A. CO URTO IS , PhD, A B PP, LI CEN SED PSYCHOLOGI ST A N D CO N SU LTA N T/TRAINE R, TRAU M A P SYC H O LOGY A N D TR AUMA TR EATMEN T; COAUTHOR O F T RE AT IN G COMPL EX TRAUMA: A SEQUENC ED, RELATI ONSH I P -BASED APP ROAC H A N D CO ED ITO R O F TREATING COMPL EX TRAUMATI C STRESS DI SORDER S I N ADULT S

The second edition of this classic text on emotion-focused therapy and trauma offers a fresh, coherent, and comprehensive perspective on the richness of emotional processes involved in the healing of wounds from adverse events. Many sufferers who need healing can be helped by the caring, compassionate, validating, but also well-informed and well-researched approach described in this incredibly clear and practitioner-friendly book. Well done and thank you to the authors for this pivotal contribution! — L A D I SL AV TIM ULAK , P h D, P RO FE SS O R I N COUN SELLI N G PSYCHOLOGY, SCHOOL OF P SYCH OLOGY, TR I N I TY COLLEGE DUB LI N , I R ELA N D

Emotion-Focused Therapy for Complex Trauma An Integrative Approach

SA N D R A C . PA I V IO & A N T O N IO PA S C UA L - L E O N E

SECOND EDITION

Copyright © 2023 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 https://www.apa.org Order Department https://www.apa.org/pubs/books [email protected] In the U.K., Europe, Africa, and the Middle East, copies may be ordered from Eurospan https://www.eurospanbookstore.com/apa [email protected] Typeset in Meridien and Ortodoxa by Circle Graphics, Inc., Reisterstown, MD Printer: Sheridan Books, Chelsea, MI Cover Designer: Mark Karis Library of Congress Control Number: 2022945999 https://doi.org/10.1037/0000336-000 Printed in the United States of America 10 9 8 7 6 5 4 3 2 1

CONTENTS

Acknowledgments ix Introduction to Emotion-Focused Therapy for Trauma: Development, Defining Features, Strengths, and Contributions

I. THEORY   1. Trauma and Its Effects

3

13 15

Definition of Trauma

16

Types of Traumatic Events

16

Prevalence and Risk Factors

18

Effects of Trauma

21

Implications for Treatment

31

  2. The EFTT Treatment Model

33

Theoretical Foundations

35

Distinguishing Features of EFTT

38

Distinctions Between EFTT and the General Model of Emotion-Focused Therapy

42

The Treatment Model

44

  3. Working With Emotion

55

Review of Emotion Theory Underlying EFTT

56

Change Processes: Emotional Processing in EFTT

62

Model of Change and Phases of EFTT

72

 v

vi  Contents

II. PRACTICE

77

Early Phase of Therapy   4. Cultivating the Alliance

79

Intervention Principles for Developing a Productive Alliance

80

Goals of Alliance Formation in Phase 1 of EFTT

85

Conducting the First Three Sessions

94

Alliance Difficulties

99

  5. Promoting Experiencing

103

Features of Experiencing

104

EFTT Compared With Other Perspectives on Experiencing

105

Experiencing Compared With Other Constructs

106

Measurement of Experiencing

107

Research on Experiencing in Therapy

108

The Process of Deepening Experiencing Step by Step

109

Guidelines for the Structured Focusing Procedure

114

Difficulties With Experiencing

120

  6. The Imaginal Confrontation Procedure

125

IC of Perpetrators

126

Intervention Principles

130

The Process of Engagement in IC

132

Steps in the IC Procedure and Corresponding Therapist Operations

138

Relationship Development in the Initial IC

143

Evocative Exploration as an Alternative to IC

145

Client Difficulties With the Initial IC

149

Middle Phase of Therapy   7. Memory Work in EFTT

153

Theory 154 Different Approaches to Memory Work

156

Goals and Processes of Memory Work in EFTT

158

Practice Guidelines for EFTT Memory Work

160

Memory Work When Memories Are Shallow

164

Memories Are Warded Off

170

Memories of Self as Defective or Damaged

173

Summary, Considerations, and Cautions

177

  8. Reducing Fear, Anxiety, and Avoidance of Internal Experience 181 Perspectives on Fear, Anxiety, and Avoidance: EFTT Compared With Other  Approaches

182

Process Diagnosis: Distinguishing Different Types of Fear and Anxiety

183

Change Processes and Goals

186

Interventions for Managing Anxiety and Fear

189

Helping Clients Allow Primary Emotional Experience

192



Contents vii 

  9. Transforming Guilt, Shame, and Self-Blame

207

Perspectives on Guilt and Shame: EFTT Compared With Other Approaches

208

Process Diagnosis: Distinguishing Different Types of Shame Experience

209

Change Processes and Goals

212

Intervention Principles Relevant to Shame

213

Interventions for Reducing Secondary Shame

215

Intervention for Primary Adaptive Shame About Violating Personal Standards

217

Intervention for Transforming Primary Maladaptive Shame

218

Compassionate Self-Soothing

225

Difficulties When Working With Fear and Shame

231

Late Phase of Therapy 10. Resolution of Interpersonal Trauma Through Adaptive Anger

235

Review of Theory and Research on the Resolution of Interpersonal Trauma

236

Anger and Trauma Across Theoretical Perspectives

238

Process Diagnosis: Distinguishing Different Types of Anger

240

Intervention Principles

243

Interventions for Changing Maladaptive Anger

246

Intervention for Promoting Primary Adaptive Anger

248

11. Resolution of Interpersonal Trauma Through Sadness and Grief

257

Traumatic Grief Across Theoretical Perspectives

258

Process Diagnosis: Distinguishing Different Types of Sadness

260

Change Processes and Goals

264

Intervention Principles for Promoting Adaptive Sadness

266

Interventions for Promoting Sadness and Grieving Losses

268

Intervention for Other Types of Sadness

274

12. Termination

279

Completion and Consolidation of Changes

280

Awareness and Acceptance of Limited Change

285

Sharing Mutual Feedback

287

Difficulties With Resolution

289

Difficulties With Therapy Termination

291

Bridge to the Future

294

Afterword 295 Appendix Appendix Appendix Appendix

A: Short Form of the Client Experiencing Scale B: Short Form of the Working Alliance Inventory C: The Degree of Resolution Scale (Short Form) D: Yoga Therapy as a Complement to EFTT: Integrating Body-Based Interventions

299 301 303 305

References

335

Index

351

About the Authors

375

ACKNOWLEDGMENTS

We want to acknowledge the courage and openness of dozens of clients who were willing to share their stories in therapy and who gave permission to have their therapy sessions video-recorded and used in future research and professional communications. Such access to real therapy sessions is invaluable to research and the training of mental health professionals, who, in turn, have been able to help hundreds of clients and their families deal with the devastating effects of child abuse trauma. We would also like to acknowledge the many professionals and trainees who participated as therapists in these therapy sessions and whose research on emotion-focused therapy for trauma we have cited throughout this book. Their dedication and skill have made invaluable contributions to the development and refinement of the treatment model. Finally, we want to acknowledge the many heads of emotion-focused therapy institutes that are part of the International Society for Emotion Focused Therapy worldwide. Their commitment and hard work have been instrumental in disseminating knowledge and training in this treatment approach.

 ix

Introduction to EmotionFocused Therapy for Trauma Development, Defining Features, Strengths, and Contributions

T

rauma, in general, involves emotionally overwhelming experiences that can have devastating psychological, physical, and societal effects. Complex trauma, specifically, involves repeated exposure to violence and betrayals of trust, frequently in relationships with attachment figures. Abuse and neglect at the hands of caregivers and loved ones at any age can be devastating, but when these experiences occur in childhood, they can have deleterious effects on development and result in a constellation of long-term effects. Documented sequelae include chronic posttraumatic stress disorder (PTSD), anxiety disorders, depression, substance dependence, self-harm behaviors, personality pathology, and enduring neurodevelopmental disruptions (e.g., nervous system dysregulation, alexithymia). Perhaps most devastating are the negative effects these experiences have on emotional development and competence, the person’s sense of self, and their capacity for interpersonal relatedness. Although experiences of abuse and neglect can involve feelings of helplessness and terror, PTSD is not necessarily a defining feature of the difficulties that can ensue. Many painful and threatening emotions, besides fear, are considerable sources of distress to individuals with histories of abuse. These include guilt, shame, and self-blame for victimization; anger at violation and maltreatment; and sadness about the many losses associated with trauma, especially trauma perpetrated by loved ones. Childhood maltreatment is disturbingly common, both in the general population and even more so in clinical samples. A history of childhood maltreatment

https://doi.org/10.1037/0000336-001 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  3

4  Emotion-Focused Therapy for Complex Trauma

is a risk factor associated with virtually every form of psychopathology in adults (American Psychiatric Association, 2013; Ingram & Price, 2010). Further­ more, because child abuse trauma is a significant risk factor for repeated victimization, most of these individuals have been exposed to multiple types of abuse and neglect, often at the hands of multiple perpetrators. Simply put, most clinicians will work with clients who have a history of complex trauma, and there is a need for training in effective treatment approaches. This book presents a manualized treatment that, on the one hand, is sufficiently specific and rigorous to be used in research and, on the other hand, is flexible enough to be used by clinicians in their daily practice. The text also can be used in graduate training programs and is consistent with the American Psychological Association (APA) recommendations to provide training in evidence-based approaches. Ultimately, the aim of this book is to present theoretical and practical aspects of emotion-focused therapy for trauma (EFTT), as well as supporting research, with enough specificity that clinicians from different theoretical perspectives can apply the complete package or integrate aspects of the model into their current practice. The model can be modified while keeping with key intervention principles to meet the needs of different clients in terms of trauma type and severity, symptom profile and severity, and length of treatment.

WHAT IS EFTT? Exposure-based procedures are considered a staple approach to helping people work with trauma. However, these are difficult and aversive experiences for clients, so noncompliance and dropout rates in these approaches are notoriously high. This makes it particularly important for clinicians to be aware of other effective treatment options. Furthermore, lasting treatment for complex trauma is not just about “feeling less fear and distress,” but also about “feeling more healthy emotion.” EFTT is an effective individual treatment modality (Paivio et al., 2010; Paivio & Nieuwenhuis, 2001) that provides this comprehensive focus and makes a strong and unique contribution to theory, research, and practice in this area. EFTT targets the constellation of disturbances associated with complex trauma. In addition to symptoms of distress and problems in functioning, EFTT particularly focuses on resolving issues with past perpetrators of abuse and neglect, usually attachment figures. Clients not only are disturbed by their current problems but also have been unable to heal these specific emotional injuries. Resolving issues with significant others and cultivating a strong therapeutic relationship reduces symptom distress, increases self-esteem, and improves global interpersonal functioning. The standard model of EFTT presented in this text involves a short-term (16–20 sessions) individual therapy for people dealing with different types of childhood maltreatment (emotional, physical, sexual abuse, emotional neglect). At the beginning of this treatment, clients identify the types of experiences and the abusive or neglectful

Introduction 5

others they want to focus on in therapy. Following that, the protocol is sufficiently flexible to address individual client treatment needs. Furthermore, while research has focused on survivors of childhood maltreatment, this work extends more broadly to relational trauma that may have occurred in other intimate and/or significant relationships during adulthood. Developments in the Emotion-Focused Approach EFTT is among a growing group of psychological treatments identified as emotion-focused approaches for specific disturbances or disorders (see Greenberg & Goldman, 2019a). As such, the current treatment for complex trauma has adapted the general emotion-focused therapy model originally proposed by Greenberg and Paivio (1997) by modifying its interventions and tailoring its structure and emphases to the specific needs of trauma victims. These developments are based on a long program of research that began in 1993 and have resulted in some key differences from the original model to suit the targeted population better. In contrast to depressed clients being treated with emotion-focused therapy, for example, chronic interpersonal trauma frequently needs to address issues of symptom management and emotional dysregulation. Moreover, individuals with PTSD or complex PTSD frequently have disturbances in narrative memory and difficulties with labeling or describing their feelings (i.e., alexithymia). Chronic avoidance and resultant poor awareness of internal emotional experience are also highly prevalent in this client group, and these deficits must be addressed in successful trauma therapy. It is also common that these clients have comorbid social anxiety and are reticent in new relationships. All these client difficulties can require a more directive style from the therapist, more explicit emotion coaching and guidance, as well as changes in emphases from the original emotion-focused therapy model. Furthermore, the classic empty-chair procedure used in emotion-focused therapy for addressing long-standing interpersonal issues or “unfinished business” with significant others is not always suitable or appropriate, in its original form, when addressing issues with perpetrators of abuse. Traumatized clients can experience considerable difficulty in imaginarily confronting perpetrators, and interventions frequently require more attention to affect regulation or the use of alternative interventions for these individuals. Compared with the original model, this task in EFTT more explicitly involves principles of gradual trauma exposure. Thus, working with complex trauma has necessitated changes to interventions as well as the addition of memory work to address a unique set of treatment needs. Finally, although the general model of emotion-focused therapy can incorporate tasks to address self-criticism or self-interruptive processes and longstanding interpersonal injuries, these tasks do not necessarily co-occur, nor do they occur in any specific order. In contrast, observations of therapy with victims of complex trauma indicated that treatment virtually always required addressing both self-related and other-related disturbances. Moreover, we found

6  Emotion-Focused Therapy for Complex Trauma

that clients were unable to resolve past interpersonal issues until self-related disturbances (fear, avoidance, self-blame) were first reduced. The result is that EFTT is a treatment innovatively structured in three sequentially ordered phases, each of which can be later revisited in a recursive fashion. Treatment Indicators and Contraindicators The characteristics of client suitability for EFTT are consistent with best practices for most trauma therapies (e.g., Courtois et al., 2017; Ford & Courtois, 2020). In general, EFTT is designed for clients who are suitable for short-term trauma-focused therapy who have the capacity to form a therapeutic relationship over a few sessions and focus on a circumscribed issue from their past—in this case, childhood trauma. The standard version of EFTT is not suitable for clients whose primary presenting problem is severe affect dysregulation with a risk of harm to themselves or others, whose current problems (e.g., domestic violence, substance dependence) take precedence over a focus on past issues or who wish to focus primarily on current rather than past relationships (e.g., a focus on parenting, marital distress). However, aspects of EFTT have been integrated into longer term treatments, ones that devote more time to training in emotion regulation skills and addressing current life difficulties that may be among the sequelae of past trauma. Strengths and Distinctive Features of EFTT The two primary change processes in EFTT are the therapeutic relationship and emotional processing of trauma memories. These are consistent with the change processes posited in other psychological treatments for trauma. Emotion-focused therapies, however, make distinct contributions to understanding and promoting these change processes. First, we emphasize advanced empathic responding as the primary intervention used throughout therapy. An empathically responsive therapeutic relationship enhances emotion regulation, promotes emotion awareness and competence, and helps to correct the effects of early empathic failures. Second, emotion-focused therapies such as EFTT are characterized by a highly differentiated approach to understanding and treating different emotion states and processes. For example, the pain of sadness and loss and the “bad feelings” associated with depression (which can include sadness at loss) are both aversive, and people can exert considerable effort to avoid both these types of experiences. However, these involve different change processes and require different intervention strategies. Similarly, hostile and rejecting anger at rejection, rage at violent harm to loved ones, suppressed anger at violation, and anger at self for having been victimized are different experiences that require different intervention strategies. A major distinguishing feature of emotion-focused approaches is their emphasis on changing emotion with emotion rather than with rational cognition or interpretations (Greenberg & Goldman, 2019a). This is the process of emotional transformation which is at the heart of EFT. Information associated

Introduction 7

with healthy adaptive emotions, such as anger at maltreatment and sadness at loss, is used to modify the maladaptive meaning associated with emotions such as fear and shame. This is particularly relevant to therapy for complex trauma because many people who have been victimized learn to suppress their feelings of adaptive anger and sadness and so have been unable to assert interpersonal boundaries and grieve important losses. EFTT also draws on well-developed technology in the experiential therapy tradition for overcoming experiential avoidance, accessing inhibited emotion, promoting meaning construction processes, and resolving attachment injuries. In this book, we present guidelines for cultivating a strong therapeutic alliance and implementing different interventions specifically tailored to these different types of emotion and emotional processing difficulties.

DEVELOPMENT OF EFTT AS AN INTEGRATIVE APPROACH AND UPDATES IN THE SECOND EDITION Emotion-focused therapies, including EFTT, integrate seminal developments in emotion theory and research and affective neuroscience that emphasize emotion as an adaptive orienting system (e.g., Damasio, 1999, 2010; Frijda, 2016; Izard, 1977, 2002; LeDoux, 2012). The EFTT emphasis on adaptive processes also is consistent with recent interests in the phenomena of trauma resilience and posttraumatic growth. EFTT especially draws on the vast theoretical, research, and practice literature in the areas of trauma and attachment (e.g., Ford & Courtois, 2020). Strengths from the cognitive and behavioral traditions, for example, include the construct of exposure to and emotional processing of trauma memories as a mechanism of change, as well as the use of memory work and emotion regulation techniques (e.g., Cloitre et al., 2006; Foa et al., 2019). Similarities with the psychodynamic tradition include an explicit focus on working through the effects of negative attachment relationships and the therapeutic relationship as a corrective emotional experience (Herman, 1992). Outside the emotion-focused therapy tradition, technically, EFTT most resembles recent experiential and dynamic or relational approaches (e.g., Fosha, 2021) that emphasize therapist empathy and experience-near interpretations. Moreover, in outlining concepts and treatment interventions in this book, we present comparisons with other treatment approaches to highlight similarities and differences. Consequently, we expect that this manual will be useful to practitioners from divergent theoretical perspectives and professional backgrounds. EFTT is fully integrative at the levels of theory, research, practice, and training—each aspect informs the other. First, as described, the model is based on a sound theoretical foundation. Second, EFTT is based on an empirically derived model that identifies steps in the process of resolving “unfinished business” with significant others (especially attachment figures) from the past (Greenberg & Foerster, 1996; Greenberg & Malcolm, 2002). This process model was further developed and refined through years of programmatic research that

8  Emotion-Focused Therapy for Complex Trauma

involved both randomized clinical trials (e.g., Paivio & Greenberg, 1995; Paivio et al., 2010; Paivio & Nieuwenhuis, 2001), as well as observation and analysis of hundreds of videotaped therapy sessions with clients working through complex trauma (e.g., Paivio et al., 2001). These process-outcome studies supported the posited mechanisms of change in therapy and thus are highly relevant to clinical practice. Contributions of EFTT to the General Model EFTT makes several contributions to the general model of EFT. First, the emptychair intervention was reconceptualized as imaginal confrontation to emphasize the trauma-related process rather than a specific technique (i.e., using furniture and literal enactments) and now speaks to the broader community working to treat trauma. This reframing considered the stressful nature of confronting trauma feelings, memories, and difficulties that a significant minority of clients had with the procedure. Thus, another contribution of EFTT to the general model was the development and evaluation of the evocative exploration protocol as a less stressful alternative for clients who decline the imaginal confrontation procedure (Paivio et al., 2010). This gave an important evidencebased treatment option. Consistent with observed client difficulties with confronting imagined perpetrators, the EFTT model for trauma also emphasizes the central importance of avoidance and addressing blocks to experiencing. Here, the term avoidance refers to a commonly recognized self-protective strategy (conscious or unconscious) for coping with painful, overwhelming, and threatening experiences. Although it is self-protective in the short term, avoidance is one of the symptom clusters of PTSD that is known to perpetuate disturbance. EFTT, as presented in the first edition of this book, also formulated the process of therapy into stages defined by the type of emotion that was the focus of therapy—undifferentiated, maladaptive, and adaptive—to help organize therapists’ ongoing case formulations. This innovation of EFTT (Paivio & Nieuwenhuis, 2001) was consistent with Pascual-Leone and Greenberg’s (2007) general empirical model of emotional processing as a core way of understanding client change (see Chapter 3, this volume). Applying this model of change to actual clinical practice (i.e., beyond process research models) set an example later adopted by a range of other EFT authors (for examples, see chapters in Greenberg & Goldman, 2019a). Updates in the Second Edition In the 10 years since the first edition of this book, there have been many significant developments in traumatology, emotion-focused therapy in general, and EFTT specifically. This second edition includes these developments and thus remains current and relevant to clinicians. First, the literature review in this volume has been updated to include the most recent scholarship, research, and practice guidelines across divergent theoretical perspectives in trauma and trauma therapy.

Introduction 9

Second, since the publication of the first edition of this book, research on the emotional change process in EFT has included more than 25 studies of diverse treatment approaches for diverse client problems, including complex trauma (Pascual-Leone, 2018). This program of research supports the validity of this model of change specifically as applied to EFTT. Relatedly, the identification of different subtypes of “emotional processing” across divergent psychotherapeutic approaches (Pascual-Leone & Greenberg, 2007) led to the development of a new and systematic approach to assessment and client case conceptualization presented in Chapter 5 of this edition. This approach includes identifying specific client emotional processing difficulties to guide intervention over the course of therapy. Third, abundant research over the past 10 years specifically on EFTT provides additional support for the treatment model and in-session change processes, including the roles of the therapeutic relationship, depth of experiencing, adaptive emotion, and narrative quality (e.g., Carpenter et al., 2016; Harrington et al., 2021; Holowaty & Paivio, 2012; Khayyat-Abuaita et al., 2019; Mundorf & Paivio, 2011). Results of these studies are described throughout this volume. Clinical material in this second edition of the EFTT book importantly includes a new emphasis and chapter on memory work and trauma reexperiencing (see Chapter 7). The focus on memory work as a distinct therapeutic task places EFTT solidly in the context of trauma therapy research supporting emotional reexperiencing of trauma memories as essential to emotional processing and change. Relatedly, this second edition explicitly delineates, for the first time, how memory work is central not only to recovery from traumatic fear but also to reducing core attachment-based shame. Guidelines for using memory work as an alternative to two-chair dialogues for self-critical processes that characterize the general model of emotion-focused therapy are presented in Chapter 9. Intensifying painful internalized critical and degrading statements in standard two-chair dialogues can be contraindicated when the message is too toxic, overwhelming, damaging, or retraumatizing (like self-annihilating statements in depression). In these situations, we found it more productive to activate and explore episodic memories of past events when a core shamebased sense of self was formed and/or recent events when this sense of self is activated. The process of helping clients to reexperience trauma memories productively involves therapeutic attention to the content and quality of client storytelling about traumatic events. A recent book by Paivio and Angus (2017) articulated the importance of narrative processes in EFTT, and that information is integrated throughout the present volume. Although the general model of emotion-focused therapy includes attention to narrative processes, this has been largely a contextual factor. This second edition of the EFTT book draws on Angus’s large body of research on narrative-emotion processes (Angus et al., 2017; Paivio & Angus, 2017) and places trauma narratives front and center in EFTT as an aid to assessment that can inform intervention.

10  Emotion-Focused Therapy for Complex Trauma

EFTT also is grounded in our combined years of training and clinical experience using the EFTT model to treat traumatized individuals. This experience has continued to shape and refine the theoretical underpinnings of the treatment. Many new clinical examples drawn from this experience are presented in this volume. In addition, since the publication of the first edition of this book, we both have conducted numerous workshops and training sessions in EFTT in Canada, the United States, Europe, South America, Asia, Australia, and New Zealand. The model thus has been further refined through dialogue with the dozens of graduate students and professional trainees from divergent professional and cultural backgrounds who have participated in these training sessions. Finally, although it stands as a separate contribution, Appendix D in this edition provides instruction on how body-based interventions might be integrated into EFTT to address the physical experiences related to psychological trauma. That contribution elaborates principles and procedures from yoga therapy for trauma, which could be used to address client difficulties with and to enhance standard EFTT interventions.

OVERVIEW OF THIS VOLUME This book is presented in two parts. Part I, Theory, introduces general concepts that are important throughout the treatment. As such, it includes four chapters. These describe relevant features of trauma (Chapter 1), a model of how EFTT addresses these features (Chapter 2), and the core construct of emotional processing (Chapter 3). Part II, Practice, describes processes and procedures in each of the phases of EFTT: • Chapters 4 through 6 cover the early phase of therapy. This includes instruction on establishing a safe and collaborative therapeutic relationship and promoting client experiencing, which are the basis of all tasks and procedures. This is followed by introducing the primary imaginal confrontation procedure (or the less stressful evocative exploration alternative) used throughout therapy to resolve issues with perpetrators. • Chapters 7 through 9 cover the middle phase of therapy, which focuses on reexperiencing trauma memories and resolving self-related difficulties (i.e., reducing fear and avoidance and transforming guilt, shame, and selfblame). These processes interfere with emotional engagement with trauma memories and with appropriately holding offenders responsible for harm. • Chapters 10 through 12 cover the late phase of therapy, which focuses on resolving past interpersonal issues by accessing adaptive anger at maltreatment and sadness at loss. Experience and uninhibited expression of these emotions and their associated meanings are the catalysts for resolving issues with offenders. Chapter 12 focuses on the termination of therapy.

Introduction 11

Intervention chapters in Part II include guidelines for distinguishing among different types of emotion and associated emotional-processing difficulties typical of trauma. These chapters also outline the central principles and goals while giving step-by-step guidelines for conducting interventions and completing therapeutic tasks. Finally, they provide guidelines for addressing client difficulties and therapist errors that typically occur in this type of therapy. The book concludes with an Afterword which places EFTT in the context of promising current approaches to the treatment of trauma, identifies several new directions for future development of EFTT, and discusses the impact on therapists of deep emotional engagement with client trauma material. In describing the phase-by-phase treatment process, this book presents case material drawn from a wide range of actual clients, all of whom have given permission to use their material in professional communications. Other cases are drawn from APA-published DVDs and unpublished videotapes that are available to the reader. Still other cases are composites. Identifying information for all clients has been deleted or disguised. Transcribed excerpts from some cases are presented verbatim, and in other instances, dialogue has been modified to illustrate intervention principles better. When a specific case is referred to repeatedly in the book, we have used pseudonyms to provide continuity for readers examining various aspects of a client’s process across treatment.

I THEORY

1 Trauma and Its Effects

M

y (S.C.P.’s) interest in trauma resulted from conducting therapy with one client early in my career as a psychologist. “Monica” sought therapy to deal with the suicide of her mother by gunshot more than 30 years before treatment. Following the suicide, the family fell apart. The father died of alcoholism a few years later, and the three children were placed in a variety of foster care settings. No one ever talked about the mother’s death; the message was, “Forget it; let it go. She was a sick woman. Get on with your life.” The mother’s suicide became the family’s “ugly secret,” and Monica could not forget about it. Although she functioned extremely well on the surface, she struggled with recurrent episodes of posttraumatic stress disorder (PTSD; e.g., avoidance of reminders, anniversary reactions) as well as feelings of shame, depression, and anger at her dead mother; the “atrocity” she committed; and her abandonment. Therapeutic work with Monica exemplified the richness, challenges, and rewards of trauma work, as well as the incredible resilience and courage of trauma survivors. The process of therapy with Monica has been analyzed from multiple theoretical perspectives, and this case became the inspiration and prototype for emotion-focused therapy for trauma (EFTT). We refer to aspects of therapy with this client throughout this text. The overall purpose of this chapter is to describe the nature of trauma and its effects. How these effects are addressed in EFTT are presented in Chapter  2, which outlines the treatment model. These chapters, therefore, should be read as a pair.

https://doi.org/10.1037/0000336-002 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  15

16  Emotion-Focused Therapy for Complex Trauma

DEFINITION OF TRAUMA The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) defines trauma within the diagnostic category of PTSD in terms of the nature of the event, which must involve an actual or perceived threat of death, serious injury, or sexual violence to self or others. From this perspective, the focus of pathology is on the emotion of fear. However, studies that specifically examine the emotions observed and reported by clients with PTSD suggest otherwise. For example, when presenting at a trauma clinic, less than 50% of cases who met the criteria for PTSD presented with anxiety as their principal emotion, while slightly over half the clients reported sadness, anger, or disgust as emotions that were more dominant than anxiety (Power & Fyvie, 2013). Furthermore, Power and Fyvie (2013) found that clients with anxiety-based PTSD were most likely to benefit from exposure-based cognitive behavior therapy. This led the authors to question the usefulness of a standard exposure-based treatment with more than half of presenting cases. From this perspective, trauma involves many emotions and emotional difficulties. This is especially the case with trauma stemming from childhood maltreatment that frequently may not meet DSM-5 criteria for trauma or PTSD.

TYPES OF TRAUMATIC EVENTS The numerous types of traumatic events differ in content and distinct features of the relationships and emotions involved. The distinct features of different types of events (e.g., natural disaster vs. sexual assault, assault by stranger vs. assault at the hands of a loved one) are associated with different problems that have implications for therapy. For example, if the perpetrator of the crime remains unidentified or not apprehended, therapy may need to focus on managing a real risk of revictimization. Crimes that do not result in severe physical injury can be met with minimization by others so that victims feel invalidated and isolated. Crimes and vehicular accidents can involve prosecution and severe losses to the self, including physical injuries that require lifelong rehabilitation and psychological treatment. The trauma literature most frequently distinguishes between two broad categories of traumatic exposure that differ in type, severity, or breadth of effects (Ford & Courtois, 2020). Single incident or limited exposure trauma, such as a car accident or industrial accident, a natural disaster, or a single assault, are thought to result in the disturbances that characterize PTSD. In these instances, it can be the severity or extremity of the event that causes disturbance. Some single events, such as the suicide of a loved one or physical and sexual assault, can have severe long-term effects. For example, the suicide of a loved one, as in the case of Monica, although a single incident, typically occurs in the context of years of family difficulties (e.g., mental illness, substance abuse) and can result in a chain of events that can last a lifetime.

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Such circumstances and effects are better understood in terms of complex trauma, which is the second broad category of trauma exposure. Complex trauma refers to repeated exposure to the threat of violence, including social, political, or domestic violence (as victim or witness) and childhood maltreatment (the predominant focus of EFTT). Complex trauma is always interpersonal in nature. Within this category, it is important to consider the age of onset, duration, relationship to the perpetrator, and the familial, social, and cultural context. Effects of these experiences include disturbances in affect regulation and problems with maladaptive meaning, particularly perceptions of self and others. War and combat trauma are examples of complex trauma that are characterized by their severity, confluence of victim and perpetrator, and sometimes lack of societal support, as in the case of veterans of the Vietnam War. The torture and political violence experienced by refugee trauma survivors and asylum seekers often involved the destruction of an entire community and may or may not have involved a perpetrator known to the victim. Frequently, however, perpetrators of interpersonal trauma are known to the victim. Instances of domestic violence and sexual abuse, for example, most frequently involve friends or loved ones as perpetrators and are followed by shame and minimization or denial, as well as social isolation. These offenses also involve a betrayal of trust and unresolved anger and sadness regarding significant others. Victims also may be trapped in ongoing abusive situations due to financial, physical, or emotional circumstances. Individuals can be further victimized by unhelpful others who minimize damage, myths about rape that generate shame and self-blame, and procedures of the judicial system. Documented effects of sexual assault include PTSD, sexual dysfunction, and cognitive–affective disruptions such as guilt, shame, and self-blame. Finally, interpersonal trauma perpetrated by intimate others can occur at different developmental stages when vulnerability to psychological disorganization is high. The trauma can involve, for example, betrayal by caregivers and violation of needs for safety, respect, interpersonal boundaries, and fundamental moral values or beliefs that compromise normal development. The most welldocumented types of these traumatic experiences are childhood physical and sexual abuse and victimization through exposure to malevolent violence (sexual assault, domestic violence). Betrayal at the hands of primary attachment figures, such as the case of Monica, who was essentially abandoned by her mother’s suicide, can have devastating effects on development. Another noteworthy type of trauma exposure concerns the phenomenon of vicarious traumatization among health care professionals treating traumatized individuals. This resembles complex trauma in that it typically involves repeated exposure (i.e., to client trauma narratives). Such vicarious traumatization has been the recent subject of considerable theory and research (e.g., Harrison & Westwood, 2009; Pearlman et al., 2020), and therapist self-care has become a component of clinical training programs. This has obvious relevance to readers of this book. Risk factors for developing disturbance resemble those for direct exposure to traumatic events that are presented in a later section of

18  Emotion-Focused Therapy for Complex Trauma

this chapter. These include repeated exposure to vivid descriptions of client traumatic experiences; unresolved personal trauma, particularly childhood maltreatment; characteristics of perfectionism, self-blame, and overresponsibility for client recovery; and an unsupportive work environment where clinicians have limited opportunity to process their experience. Obvious corresponding protective factors include a balanced practice (if possible) that limits the number of traumatized clients, personal therapy to resolve past trauma, and seeking support from professionals and colleagues. As in direct exposure to traumatic events, effectively dealing with vicarious traumatization requires the capacity to experience and express the many intense negative emotions associated with trauma.

PREVALENCE AND RISK FACTORS It is important to distinguish between exposure to trauma and the development of disturbance. Many more individuals are exposed to trauma than develop a diagnosable disorder. However, in general, the risk of both exposure and disturbance increases with each exposure. It is sad to note that the more vulnerable an individual is to begin with, the more likely they are to be exposed to trauma and suffer long-term negative effects. The following review of statistics concerning prevalence and risk factors is intended to highlight the need for effective treatment options and clinician training in this area. Exposure to traumatic events, in general, is no longer considered rare. A recent review of the literature (Sareen, 2018) reported that in a sample of 5,692 respondents in the United States, 82.7% were exposed to severe and potentially traumatic events. Moreover, epidemiological studies have consistently found that exposure to multiple traumatic events is quite common (Kilpatrick et al., 2013). This is reflected in the current definition of Criterion A for PTSD in DSM-5, which refers to exposure to “traumatic event(s)” rather than “event” as it appeared in DSM-IV-TR (American Psychiatric Association, 2000). These rates do not reflect the increasing numbers of refugee trauma survivors who now reside in developed countries. According to the United Nations High Commissioner for Refugees (UNHCR; 2020), for the first time, 1% of the entire human population is uprooted. A report at the end of 2019 found that over the previous decade, over 100 million people have been forcibly displaced, fleeing violence, persecution, political threat, and human rights violation. Today, almost 80 million of those cases remain unresolved, and 40% of them are children (UNHCR, 2020). These numbers point to a new and mounting frontier for mental health services. Many of these people have suffered multiple accounts of complex trauma, including being a victim of torture. The core treatment concerns here include profound existential issues of personal identity in relation to others.

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Similarly, the implication of relational and identity issues can often make combat-related trauma more complex than it may appear (Cox et al., 2014). Human trafficking is now recognized as an entrenched problem in industrialized nations. Victims include young women forced into the sex industry as well as men and boys who are put into forced labor. According to Polaris (2020), over a 5-year period in the United States (2015–2019), there were over 63,000 separate cases of human trafficking, with 70% of those trafficked under the age of 18. Contrary to widespread belief, most victims did not cross international borders but were victimized in local communities, and frequently the perpetrator was known to the victim. Providing effective treatment for the increasing numbers of these cases of complex trauma is a challenge for mental health service providers. Using an emotion-focused approach has shown promise with combat-related trauma (Blow et al., 2015; Mikaeili et al., 2017), refugee trauma survivors (Paivio & Kuo, 2007), and victims of human trafficking (Pascual-Leone et al., 2017). Childhood Maltreatment In terms of complex trauma, despite increased attention by public policy and mental health professionals to issues of family violence and child maltreatment, recent surveys indicate that child abuse in the general population remains disturbingly common. It is currently recognized that repeated exposure to trauma in the home is far more prevalent than single-incident trauma. Furthermore, multiple types of maltreatment usually co-occur in the same family, so victims are exposed to multiple types of traumas. A recent meta-analytic study examined international prevalence rates for different types of childhood maltreatment (Moody et  al., 2018). This study found that rates differed by maltreatment category, gender, and continent. For example, sexual abuse prevalence was 20.4% and 28.8% in North American and Australian girls, respectively, with lower rates generally for boys. Rates of physical abuse were more similar across genders, except in Europe, where the rates were 12.0% for girls and 27.0% for boys. Rates of physical abuse were high in some continents—for example, 50.8% for girls and 60.2% for boys in Africa. This could reflect the higher rates of culturally normative physical discipline in developing countries. Higher rates of emotional abuse were found for North American girls (28.4%) compared with boys (13.8%), but lower rates were found in Europe, with 12.9% for girls and 6.2% for boys. Rates elsewhere were more similar across gender groups. Median rates of neglect differed between girls (40.5%) and boys (16.6%) in North America but were similar in Asia (girls: 26.3%, boys: 23.8%). Rates of neglect were highest in Africa (girls: 41.8%, boys: 39.1%) and South America (girls: 54.8%, boys: 56.7%) but were based on few studies. Despite this variability, these results indicate the high prevalence of childhood maltreatment worldwide. At the time of this writing, because of increased social isolation, confinement at home, and economic stress during the global COVID-19 pandemic, child protection services internationally

20  Emotion-Focused Therapy for Complex Trauma

are reporting increased rates of intimate partner violence and all forms of childhood maltreatment (Katz & Fallon, 2020). There is less research on emotional maltreatment and more variability in reported prevalence estimates because of differing characteristics, definitions, type of maltreatment assessed, and lack of operational definition (absence of a gold standard). Nonetheless, Taillieu et al. (2016) reported that 14% of the U.S. adult population reported experiencing childhood emotional maltreatment from a parent or caregiver before the age of 18. Among respondents, 6.2% reported neglect only, and 4.8% reported abuse only; all types co-occurred with other types of maltreatment, particularly physical abuse. The reported prevalence means there is a specific need for effective treatments for the effects of interpersonal developmental trauma. Furthermore, as we have seen, early victimization increases the risk of subsequent exposure through, for example, family violence or criminal victimization such as rape. This compounding of risk, in addition to the extremely high prevalence of childhood maltreatment history in clinical samples, leaves little doubt about the long-term negative effects of these childhood experiences. Prevalence of Disturbance As noted earlier, childhood adversity is a risk factor for almost every major form of adult psychopathology (Ingram & Price, 2010; DSM-5). A Canadian community health survey (Afifi et al., 2014) of 23,395 respondents 18 years and older studied the effects of three types of childhood abuse (physical, sexual, intimate partner violence). Results indicated that all three forms of childhood abuse were associated with all forms of mental disorders studied (generalized anxiety, panic, obsessive-compulsive disorder, depression, substance abuse), including suicide ideation and attempts. An increased number of abuse types were associated with greater odds of mental conditions. Among the disturbances associated with childhood adversity, PTSD is specifically associated with trauma exposure. Most people exposed to traumatic events do not develop PTSD. Nonetheless, estimated rates for the disorder in the general population are high, and its onset can be delayed for months or even years following the traumatic event. Research has shown that the rates and symptom presentation of PTSD differ across types of traumatic events, with interpersonal trauma frequently associated with a higher probability of PTSD and more severe symptomatology than noninterpersonal trauma (e.g., Kessler et  al., 2017). Numerous studies have found that cumulative trauma, mostly defined as a buildup of different trauma types, is associated with greater PTSD risk and symptom severity (e.g., Wilker et al., 2015). A recent review of the literature on prevalence rates of PTSD in the general adult population in the United States and Canada (Sareen, 2018) reported the lifetime prevalence ranges from 6.1% to 9.2%, with 1-year prevalence rates of 3.5% to 4.7%. Higher rates of PTSD have been found in population subgroups in the United States compared with the general U.S. population,

Trauma and Its Effects  21

including Native Americans living on reservations and refugees from countries where traumatic stress was endemic. Although factors are unclear, lower prevalence rates have been found outside North America (e.g., Europe and Australia). Although well-controlled studies of PTSD prevalence in developing countries are scarce, many scholars believe that rates in these countries are higher than in more economically developed regions because of a lack of resources to avert disasters and mitigate their aftermath. There are increasingly large numbers of refugee trauma survivors in North America from both developing countries and “failed states.” Sareen (2018) reviewed reports of PTSD prevalence regarding mass conflict and displacement. A meta-analysis of 145 studies of 64,332 refugees and other conflict-affected individuals internationally found a mean PTSD prevalence rate of 30.6%. Factors associated with higher PTSD rates included reported torture, cumulative exposure to potentially traumatic events, shorter time since conflict, and the assessed level of political terror. Moreover, the reported prevalence of PTSD and related health problems in this refugee population is likely underestimated. These individuals are frequently reluctant to use mental health services because of financial and language barriers and uncertain refugee status. Furthermore, these individuals are rarely questioned about their trauma history when they arrive at emergency clinics. This large-scale migration is a relatively recent phenomenon, and there is ignorance on the part of many health care professionals about the mental health needs of this group.

EFFECTS OF TRAUMA Outlining symptoms and how individuals are affected by trauma helps to delineate the targets for treatment and the deeper issues that people suffering from trauma also experience. These present complications to treatment are over and above the initial presenting symptoms. In this section, we outline the effects of trauma in terms of symptoms, self-related and interpersonal problems, and emotion regulation difficulties, and the specific effects of different types of development trauma. We conclude with treatment implications. Symptom Development Basic trauma theory states that traumatic experiences are encoded in memory as a multimodal network of information or fear structure (Foa et al., 2019). Information includes neurobiological, cognitive, affective, and stimulus– response aspects of the traumatic situation such that stimuli resembling the traumatic event activate the entire network or structure. This understanding of the development of trauma symptoms forms the basis of most trauma therapies, including EFTT. From a learning perspective, classical conditioning is thought to account for the development of chronic PTSD, whereas operant

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conditioning is thought to account for the maintenance of disturbance (i.e., the avoidance of trauma feelings and memories is a negative reinforcer). PTSD reactions occur, not only in response to reminders of the trauma but also in response to intense albeit neutral stimuli (e.g., loud noises), indicating a loss of stimulus discrimination and an increasingly narrowed “window of tolerance” for nervous system regulation in response to triggers (Pessoa, 2013; Porges, 2011). Most studies suggest that trauma memories tend to be implicit, behavioral, and somatic. They also can be vague, overgeneralized, fragmented, and incomplete and, as such, are associated with disorganized personal narratives. Seminal theory and research (van der Kolk & McFarlane, 1996) have indicated that traumatic experiences are encoded primarily in right-brain experiential (nonverbal) memory in the form of emotions, images, and bodily sensations but are not processed on a symbolic or verbal level and are left unintegrated with other life experiences. Results of neuroimaging studies of individuals recalling trauma memories (e.g., Lanius et al., 2004) suggest increased sensory processing, especially of visual information, accompanied by decreased verbal processing. These findings are consistent with clinical observations of low verbal processing and high sensory experiencing by trauma survivors. This supports the need for therapeutic procedures, such as those used in EFTT, that access experiential memories and help clients verbally symbolize their meaning. There also is agreement about the neurobiological effects of trauma exposure—the fear responses associated with trauma results in hyperarousal (fight or flight) and shutting down (freeze) the nervous system, release of stress hormones, and muscle tension. With repeated exposure, as in complex trauma, these effects are reinforced and become entrenched, resulting in chronic nervous system dysregulation (Ford, 2020; van der Kolk, 2020). Posttraumatic Stress Disorder While DSM-IV-TR classified PTSD as an anxiety disorder, DSM-5 now classifies PTSD and other similar disorders as trauma- and stressor-related disorders. Still, PTSD is an affective disorder, and psychological treatments, regardless of theoretical orientation and techniques, need to address these affective disruptions. PTSD is diagnosable after 1 month of symptoms following a traumatic event. Symptoms are categorized into four clusters: intrusion, avoidance, cognitive and mood alterations, and changes in arousal and reactivity. Intrusive symptoms include phenomena such as nightmares and flashbacks. In essence, traumatic experiences are unforgettable, outside of an individual’s ordinary experience, and not easily integrated into one’s current meaning systems. Intrusive memories, rumination, and perseveration are conceptualized as attempts to process and integrate the trauma (Foa et al., 2019). A diagnosis of PTSD requires the endorsement of at least one of five symptoms listed in the intrusion cluster of DSM-5. Severe intrusive symptoms need to be managed to permit the processing of trauma memories.

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Avoidance essentially compensates for intrusion. Avoidance strategies include “shutting down,” dissociating, suppressing feelings and memories of the trauma, avoiding situations reminiscent of the trauma, and using maladaptive behaviors such as substance abuse and self-injury. Numbing is thought to be the hallmark of PTSD and linked to depressive shutting down. Avoidance is adaptive in the short term but in the long term is thought to prevent the processing and integration of trauma and perpetuate trauma symptoms (Foa et al., 2019). A DSM-5 diagnosis requires the endorsement of one of the two avoidance symptoms listed in this cluster. Alterations to arousal and reactivity are often experienced as hyperarousal, which refers to chronic overstimulation of the nervous system, whereby the body constantly is on the alert for danger (van der Kolk, 2015). Symptoms include increased heart rate, blood pressure, and skin conductance in response to sounds, images, and thoughts that resemble the trauma. These responses eventually can get paired with neutral stimuli as well. Hypervigilance and chronic anxiety are common among survivors of trauma, especially those who grew up in environments of unpredictability and threat of harm. Chronic irritability and anger also are manifestations that can be particularly problematic; anger control problems often are comorbid with PTSD and can be an intervention priority. A diagnosis of PTSD requires the endorsement of two of the six symptoms listed in the hyperarousal cluster of DSM-5. Hyperarousal can result in psychosomatic complaints and physical problems such as headaches, hypertension, back pain, and gastrointestinal difficulties. Cognitive disruptions were considered correlates of a PTSD diagnosis in DSM-IV-TR and are now a symptom cluster in DSM-5. These disruptions include memory gaps, negative views of self and the world, self-blame, and interpersonal alienation. Memory gaps are thought to be a function of levels of fear interfering with information processing, narrowing of attention focus during the event, and trauma areas of the brain responsible for meaning creation and autobiographical memory. Changed views of self, others, and reality that define PTSD are the “shattered assumptions” described by Janoff-Bulman (1992) in her classic volume on trauma. People’s previctim view of self and the world involves basic assumptions about invulnerability, personal safety, others as mostly trustworthy, and a just world. Trauma introduces new data that are incompatible with these assumptions. Following exposure to trauma, people are hypervigilant and can experience deep feelings of shame, self-blame, survivor guilt, distrust, and alienation. Exciting new adjunct treatments use psychedelics to specifically address feelings of alienation from society and humanity that result from trauma (M. W. Johnson et al., 2019). Thus, importantly, the PTSD symptom cluster of cognitive disruptions includes not only beliefs or perceptions but also intensely negative feelings concerning self, others, and the world. From an emotion-focused perspective on trauma, these are core cognitive– affective processes, a view that is also consistent with current neuroscience (Pessoa, 2013).

24  Emotion-Focused Therapy for Complex Trauma

These maladaptive feelings and beliefs are partly attributable to explicit statements or implicit messages (i.e., experiences) from perpetrators. Guilt, shame, and self-blame, especially, also are attributable to the “fundamental attribution error”—that is, the social–psychological attributional bias of blaming the victim rather than the situation or circumstance. Trauma survivors have internalized this tendency. Profound victimization also involves profound powerlessness, loss of control, and humiliation. Interpersonal alienation is partly a function of expecting blame from others and difficulties disclosing experiences of humiliation, as well as the belief that others could not understand such extreme experiences. Furthermore, the National Comorbidity Study (American Psychiatric Association, 2000) found that PTSD is associated with increased rates of major depressive disorder, substance-related disorders, panic disorder, agoraphobia, obsessive-compulsive disorder, generalized anxiety disorder, social phobia, specific phobia, bipolar disorder, and borderline personality disorder. These can precede, follow, or co-occur with PTSD. Thus, psychological treatments for PTSD frequently need to address multiple disturbances. EFTT views depression as the activation of a core sense of self as weak and bad developed in early attachment relationships and the collapse into feelings of powerlessness and worthlessness. Similarly, EFTT views anxiety disorders as the result of growing up in an environment of fear, uncertainty, and constant negative evaluation by attachment figures. This leads to the development of a core sense of self as insecure, defective, and/or inferior and therefore vulnerable to harm, negative evaluation, and abandonment. These client problems have implications for therapy processes in terms of difficulties establishing safety and trust in the therapeutic relationship and participation in key interventions. Complex Traumatic Stress Disorder Complex traumatic stress disorder (Ford & Courtois, 2020) is the commonly accepted construct now used to describe the complex array of disturbances associated with repeated exposure to interpersonal violence beginning in childhood. Although DSM-5 has not recognized this as a separate diagnostic category, complex posttraumatic stress disorder (CPTSD) has been included as a diagnostic category in the International Statistical Classification of Diseases and Related Health Problems (11th ed., World Health Organization, 2019). CPTSD consists of six symptom clusters: the three PTSD criteria of reexperiencing, avoidance, and hypervigilance, in addition to three disturbances of self-organization, defined as emotional dysregulation, interpersonal difficulties, and negative self-concept. Again, PTSD symptoms are part of this array, but defining features of the CPTSD diagnosis are disturbances of self. This means that many emotions besides fear (i.e., rage, shame, resignation) are at the heart of disturbance. CPTSD also co-occurs with borderline personality disorder (Jowett et al., 2020). This recognition of CPTSD as a separate diagnostic category is based on abundant research in the area. Trauma symptoms may be especially severe

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and long lasting when the trauma is complex and interpersonal, particularly when these traumatic experiences occur in childhood. Overall, it seems clear that effective psychological treatment for prolonged exposure to complex interpersonal trauma must be multidimensional and integrative. Self-Related and Interpersonal Problems Both self-related and interpersonal problems associated with attachment injuries are well documented (e.g., Ford & Courtois, 2020). Perceptions of self and others formed in early attachment relationships are encoded in memory and act as enduring prototypes that influence current perceptions and behaviors. Attachment theorists and researchers (e.g., Schore, 2019) emphasize the importance of parental empathy as the basis for establishing healthy representations of self and others and a secure attachment bond. This bond, in turn, is the basis for developing emotion awareness and regulation capacities, self-confidence, and interpersonal trust. Through empathic mirroring of feelings and needs, the child learns to recognize, label, and describe emotional experiences. This contributes to self-control, self-definition, and interpersonal connectedness through the development of communication skills. Self-Related Problems Impairments to the sense of self that result from childhood maltreatment include limited awareness of internal experience (i.e., feelings, wants, needs, values) that allows individuals to build a sense of self as separate from others. This results in identity confusion and fragmentation, guilt and self-blame for the abuse, and a pervasive sense of worthlessness, powerlessness, and victimization. In the absence of adequate parental emotion coaching and support, these intensely painful negative feelings and experiences, in turn, are associated with poor affect regulation, tolerance for being alone and of criticism, self-soothing capacities, and sense of personal agency. These dimensions are captured in the emotion-focused therapy construct of different emotion schemes (Greenberg, 2019; Greenberg & Paivio, 1997)—in this case, maladaptive emotion schemes that regulate one’s sense of self in the world. The area of autobiographical memory and disruption of narrative processes through trauma have recently received considerable attention. Through the effects of trauma on cognitive–affective processes identified earlier (attention, information processing, avoidance), trauma survivors frequently are not able to make sense of their experience and the associated feelings. These disruptions are evident in impoverished trauma narratives that are fragmented and incoherent, with limited insight and affective content. Moreover, the factors combined with implicit and explicit messages of blame result in erroneous interpretations that are evident in trauma narrative content. Ultimately, impoverished autobiographical memory and personal narratives reflect an individual’s self-identity, sense of self, and reality. This, in turn, negatively affects functioning, particularly interpersonal functioning. Narrative approaches to therapy directly target this area, but any approach that

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targets meaning construction processes, including EFTT, will address auto­ biographical memory and the narrative processes that were disrupted by trauma. This is the explicit focus of Chapter 5. Interpersonal Problems Problems with self-organization stemming from complex trauma during development, by definition, also are interpersonal in nature. These include difficulties with intimacy and trust, self-assertion, and interpersonal boundaries, as well as marital and parenting problems and an overall sense of isolation and alienation. Survivors who are externally focused and attuned to signs of danger can be overly vigilant and highly attuned to the needs of others at the expense of awareness of their own feelings and needs. Survivors can be especially sensitive to anger cues, and although the capacity to detect anger quickly is likely adaptive in threatening environments, this bias could be detrimental to interpersonal relationships outside of the maltreatment context. In sum, the character structure and the core sense of self for individuals exposed to complex interpersonal trauma in development center on feelings of fear and shame and difficulties regulating these experiences. Thus, problems with self-esteem, trust, impulsivity, and maladaptive avoidance of internal experience are prevalent in this population. Marital Distress As we have seen, trauma can disrupt an individual’s capacity for interpersonal connectedness, intimacy, and secure attachment—that is, the capacity to respond to and provide comfort, safety, and support. This is observed, for example, in combat personnel with symptoms of PTSD who, through exposure to extensive and extreme trauma, understandably feel isolated and alienated from civilian society (Weissman et al., 2017). These individuals can be distant or angry in their marital relationships and may experience guilt and intrusive symptoms such as flashbacks. Marital distress can also result from earlier attachment traumas that have disrupted the individual’s capacity for intimacy and trust. A prominent approach to emotion-focused therapy for couples (S. Johnson, 2002) is based on attachment theory and has been applied to marital distress resulting from unresolved trauma. When one partner in the relationship is dealing with the effects of trauma, their capacity for secure attachment may be seriously compromised. The goal of this marital therapy with traumatized couples is to help each partner reconnect with their own and their partner’s emotions and attachment needs that are being defended against through anger and distancing behaviors. Many clients in individual therapy for trauma also experience marital distress, and resolving their attachment injuries and trauma can generalize to improving a marital relationship. Still, emotion-focused therapy for couples is an important additional resource. Transgenerational Transmission of Trauma and Parenting Difficulties Emerging research on epigenetics (Yehuda & Lehrner, 2018) strongly supports the transgenerational transmission of traumatic experiences. One of the

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well-documented effects is the relationship between unresolved childhood trauma and parenting difficulties. Seminal research, for example, found that unresolved trauma in the mother, assessed using an Adult Attachment Interview, predicted disorganized attachment in her infant (Main, 1991). Caregivers who did not receive adequate parenting themselves and have not adequately developed the capacity for secure attachment seem to have difficulty providing adequate parenting. Studies indicate that women with these issues tend to misinterpret their infants’ and children’s behavior by attributing malicious intent. Moreover, they have been found to overstimulate and frighten rather than soothe distressed infants and are not appropriately responsive to their children’s emotional needs. Similarly, maternal depression, which is highly correlated with unresolved trauma, is associated with the neglect of children. Children of holocaust survivors, for example, or clients whose parents have immigrated from war-torn countries or lived through violent revolutions, such as in Iran or China, may also show symptoms of PTSD, depression, and anxiety. The traditional intervention approach to parenting difficulties has been to teach parenting skills. However, helping these parents resolve their trauma and attachment injuries also can contribute to improved parenting behavior. Indeed, it is revealing that the motivation for seeking therapy for many clients in EFTT is to become better parents and stop the cycle of abuse and neglect. Deficits in Emotional Competence Deficits in emotional competence include poor awareness and regulation of emotion, which, in turn, interfere with the capacity to reflect on emotion. These disruptions are at the heart of disturbances stemming from trauma, particularly complex trauma. Difficulties recognizing and labeling emotional experience (alexithymia) are associated with a host of long-term impairments in functioning. Likewise, affect dysregulation and avoidance problems in childhood can interfere with core developmental tasks and become habitual ways of dealing with affective experience. Moreover, these problems with dysregulation can result in long-term problems, including chronic depression and anxiety; numbing of affective experience; anger control problems; and the self-esteem and interpersonal difficulties noted earlier. According to Schore (2019), secure attachment facilitates the experiencedependent maturation of the right brain that is centrally involved in the adaptive regulation of motivational states, including aggression. Severely traumatic attachments result in structural limitations of the early-developing right brain; functional deficits include an inability to regulate emotional states (both fear or terror and aggression) under stress. Numerous neurobiological studies have documented these effects of childhood maltreatment on the developing brain (Cabrera et al., 2020). From a social developmental perspective, Gottman’s (1997) seminal work highlighted the importance of parents’ responsiveness to their children’s feelings and needs and parents’ emotion socialization and coaching (accurate labeling

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and appropriate expression) in enhancing emotional competence in their children. Effective emotion regulation is necessary for children to reflect on and understand emotionally laden experiences. From an emotional development perspective, emotion regulation includes the capacity to access the full range of emotional experience, modulate the frequency and intensity of emotional experience, and appropriately express one’s emotions and associated needs (Gross, 2015). Through empathic responsiveness of caregivers, children learn to dampen or intensify emotion in specific situations, and negative feelings, such as anger or fear, are associated with improvement and positive outcomes, such as problem solving or receiving support. However, in violent, abusive, and neglectful environments, there are limited opportunities to communicate, receive support for, understand, and appropriately express emotional experiences—especially negative ones. In the absence of suitable emotional coaching and support, children learn to rely on avoidance to cope with the powerful feelings generated in response to their maltreatment. Often, emotional overcontrol is a strategy for coping with high levels of internal distress, and the individual may alternate between the two extremes of under- and overregulation. Effects of Underregulation of Emotion It has long been known that the chronic threat of violence can result in extreme emotional arousal that is embedded in memory (van der Kolk & McFarlane, 1996). Automatic alarm reactions continue to be inappropriately triggered by current stimuli that resemble past experiences and activate the fear memory. This is evident in the intrusion and arousal symptoms of PTSD. The overwhelming emotions generated by the environment have a disorganizing effect on thought and behavior and interfere with learning, performance, and social relations. Among adult survivors, underregulation problems include intense alarm, rage, or shame responses and a pervasive sense of self as insecure or worthless, as well as chronic “bad feelings” such as anxiety, depression, and irritability (Schore, 2019). Dissociation and behaviors such as substance abuse and self-harm can be reactions to overwhelming affect. Anger regulation problems and aggressive behavior also are highly correlated with unresolved trauma (i.e., irritability, the hyperarousal symptom cluster of PTSD), particularly with exposure to physical violence; this can have profoundly deleterious effects on interpersonal relations. There is strong evidence linking early exposure to domestic violence with later interpersonal violence (Wolfe, 2007) and with a high prevalence of extreme anger and aggressive behavior among combat veterans (Novaco, 2007). Problems with anger and aggression are discussed further in Chapter 10. Effects of Emotional Inhibition and Overcontrol Avoidance of trauma feelings and memories is a feature of PTSD and a strategy for coping with symptoms of intrusion and hyperarousal. Trauma survivors often wish they could excise the feelings and memories associated with traumatic events, but avoidance means that a person is incapable of benefiting from

Trauma and Its Effects  29

past experiences. Furthermore, if avoidance is complete, these individuals do not understand their perceptions and reactive behavior. This is consistent with the perspective that internal experience and emotions are valuable sources of information and with prominent theories and research linking experiential avoidance to poor outcomes for substance abuse, depression, and anxiety (Hayes et al., 2012). According to inhibition theory, for example, the chronic inhibition of trauma feelings and memories contributes to immune system breakdown (Pennebaker & Chung, 2011) because deliberate suppression of the thoughts and particularly the feelings associated with upsetting events requires system energy (i.e., traumatic events are unforgettable). Such suppression over a prolonged period places added stress on the organism, which eventually contributes to immune system breakdown. This is consistent with the somatic complaints that are part of complex PTSD. Chronic inhibition of thoughts and feelings associated with traumatic events also is thought to perpetuate PTSD symptoms and interfere with recovery (Foa et al., 2019). Traumatic experiences and associated meanings thus are unprocessed, remain “frozen” in memory, and continue to negatively influence current perceptions of self, others, and reality. Core internal experiences that are suppressed remain “unfinished business” pressing for integration and intruding on current awareness (Paivio & Greenberg, 1995). Similarly, from an EFTT perspective, the strategies such as dissociation, disavowal, and overcontrol used by child abuse survivors to manage painful affect cut them off from the information associated with emotional experience that might otherwise aid in adaptive functioning. Consequently, survivors frequently are unable to assert themselves or grieve and heal from important losses. This has an additional disruptive effect on their everyday functioning. These difficulties are evident in alexithymia, which involves deficits in the capacity to recognize and describe emotional experience. Currently accepted social developmental theories suggest that these deficits originate from poor emotion coaching during childhood. A review of early research on alexithymia indicated that this condition was associated with a broad range of disturbances, including somatization, depression, social anxiety, and poor social support (Taylor et  al., 1997). In an outpatient population, alexithymia mediated the impact of abuse during childhood and having somatic complaints as an adult (Ogrodniczuk et al., 2014). A study of undergraduate students found that alexithymia also mediated the links that childhood maltreatment and poor maternal emotion socialization jointly had in predicting insecure attachment later during adult relationships (Mlotek, 2019). Alexithymia was also found to mediate the relationship between childhood maltreatment and self-injurious behaviors (SIBs) such as self-cutting or burning (Paivio & McCulloch, 2004). Furthermore, it is widely accepted that SIBs (and other self-destructive behaviors) frequently are used to regulate affective states, particularly anger. Together, these findings suggest that a history of maltreatment is, in part, causally related to difficulties identifying emotional experiences, and this, in turn, can lead to somatic symptoms, self-destructive behavior, and trouble feeling secure in relationships.

30  Emotion-Focused Therapy for Complex Trauma

Specific Effects of Different Types of Trauma in Development The most pervasive long-term effects of exposure to trauma are associated with cumulative and complex trauma, particularly interpersonal trauma during development. In terms of the effects of childhood abuse, overall, there are more commonalities than differences across different maltreatment subtypes. This is partly attributable to the co-occurrence of multiple types of abuse in the same family. Furthermore, a history of more types of abuse is related to greater psychopathology. Nonetheless, research has focused on identifying differential effects for different types of abuse because these potentially have implications for effective treatment. Literature on the effects of childhood maltreatment has focused mainly on female sexual abuse, with the balance of work focusing on physical abuse. Abundant research supports the pernicious effects of sexual victimization, not only on sexuality and sexual development but also on development and self-regulation across the range of affective, physical, cognitive, and social domains (van der Kolk, 2020). The distinct features of childhood sexual abuse center on sexuality and bodily experience. These include sexual dysfunction (e.g., avoidance, promiscuity), shame (including body shame), somatization, stigmatization, and vulnerability to revictimization. Childhood sexual abuse also has been found to increase the vulnerability of high school students to cyberbullying and sexual predation (Hébert et al., 2016)—forms of victimization that are becoming increasingly common. Childhood physical abuse frequently involves a combination of physical danger or terror as well as distrust. A review of the research shows correlates with a history of childhood physical abuse that echo those also documented for sexual victimization (Ford, 2020); however, the distinct effects of physical abuse center on anger control problems and aggressive behavior, particularly among males. To date, there is less research on the long-term effects of emotional maltreatment and the distinctions between emotional abuse and neglect. Definitions of emotional abuse include assaults on a child’s sense of worth or well-being or any humiliating, demeaning, or threatening behavior directed toward a child by an older person. Individuals can be unsure whether what they experienced was “abuse” and therefore may discount the effects. In our experience, this type of emotional abuse frequently is associated with self-critical processes, fear of negative evaluation, and social anxiety in adulthood. These observations have obvious implications for the therapeutic relationship and participation in key treatment interventions. Emotional abuse can also include witnessing violence perpetrated against loved ones, cruelty to pets, threats of harm to self or others, and being disciplined with weapons. Some of these experiences involve terror and horror and thus meet the DSM-5 Criterion A definition of trauma. Our experience with these clients in EFTT also suggests their susceptibility to depression— that is, a collapse in the face of their powerlessness and helplessness to protect loved ones. Recent research found that children who witnessed partner

Trauma and Its Effects  31

violence were more than twice as likely to have suffered four or more other types of traumas, which were significantly related to functional impairments (Stover et al., 2019). Furthermore, when adults seek treatment for their anger problems, they may not initially identify underlying issues related to complex trauma. However, one of the only studies on comorbidity with anger problems found that over 18% of men who voluntarily attended treatment for their violent behavior (e.g., intimate partner violence) also received a diagnosis of PTSD (Askeland & Heir, 2014). A study of the effects of childhood emotional maltreatment (Taillieu et al., 2016) found that these experiences were associated with other forms of childhood maltreatment and family dysfunction. Moreover, both abuse and neglect were associated with multiple mental disorders, including depression, anxiety, substance abuse, and personality disorders, and some effects were independent of other forms of child maltreatment and family dysfunction. The effects appeared to be greater for abuse compared with neglect. Taillieu et al. (2016) speculated that emotional abuse may be particularly harmful because damaging negative messages are directly given to children (e.g., you are worthless). This study also found that emotional abuse was more nonspecific compared with neglect and manifested across a broad spectrum of mental disorders across the life span. Authors have suggested that specific types of emotional abuse (e.g., terrorizing vs. harsh criticism) have specific effects on mental health (e.g., fear vs. shame-related disorders). Emotional neglect, however, refers to the failure of caregivers to provide for a child’s basic psychological and emotional (attachment) needs. The effects of neglect are insidious, even more so than for emotional abuse because it is more nebulous. In the Taillieu et al. study (2016), childhood emotional neglect was associated with lifetime diagnoses of specific mental disorders (e.g., major depression, social phobia, as well as schizoid, schizotypal, borderline, and avoidant personality disorders). These disorders seem to suggest social withdrawal and difficulty with interpersonal relationships. The lack of affection and support that characterizes emotional neglect likely influences attachment patterns throughout the life span (Bowlby, 1988). In our research on EFTT, we have observed that, at first blush, clients with a history of emotional neglect frequently appear to be socially anxious and emotionally constricted. But more important, these clients also possess an underlying lack of clarity or uncertainty about internal experience and looking to others, including the therapist, for direction. The implication here is that these individuals will need more support in labeling and using their internal experience for direction.

IMPLICATIONS FOR TREATMENT The statistics cited earlier indicated that repeated exposure to trauma and maltreatment, especially in childhood, has multiple, cumulative, and longlasting detrimental effects on mental health. This means that large numbers of individuals seek therapy to address these effects. With the increasing numbers

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of asylum seekers worldwide, the need for trauma-focused psychological services also is increasing. A comprehensive treatment is required that addresses the multifaceted array of disturbances and the cumulative nature of multiple discrete traumas across someone’s life. Because traumatic experiences are largely encoded in experiential memory, effective interventions to counteract the effects of trauma need to evoke the experiential system (van der Kolk, 2020). EFTT is such a comprehensive, experientially focused treatment. Therapeutic experiences that counteract the effects of trauma in EFTT take place through the therapeutic relationship, imaginal confrontation of offenders, memory work and reexperiencing procedures, and a focus on accessing previously inhibited adaptive emotional experience. EFTT techniques access and promote the processing of intense emotion that is inherent in traumatic experiences. Accessing core emotion accesses the information associated with emotional experience, which includes dissociated and ignored aspects of self, as well as healthy resources that guide adaptive functioning. Such autobiographical information and self-reflection are important in constructing more adaptive and coherent narratives. The following chapter presents the theoretical model and outlines how EFTT addresses the effects of complex interpersonal trauma.

2 The EFTT Treatment Model

T

he purpose of this chapter is to present how emotion-focused therapy for trauma (EFTT) conceptualizes and addresses the disturbances produced by trauma that were outlined in the preceding chapter. The chapter begins with the origins and development of EFTT, followed by theoretical foundations and features that distinguish EFTT from other approaches to trauma therapy and from the general model of EFT. The chapter concludes with a description of the treatment model, including phases and tasks of therapy, intervention principles, and specific procedures or techniques typically used in therapy. As described in the Introduction, EFTT has been developed and refined through a program of research spanning more than 30 years and involving the treatment of several dozen clients. This program began with clinical observation and, later, process analyses of emotion-focused therapy for “unfinished business” (Paivio & Greenberg, 1995) with clients who were specifically dealing with issues of child abuse trauma. Several key features of EFTT emerged from these observations and analyses. First, participation in the primary imaginal confrontation (IC) procedure used in therapy seemed more difficult for clients who were dealing with issues related to trauma. This procedure requires clients to imagine perpetrators of abuse in an empty chair and express their thoughts and feelings directly to them. When this was first introduced in therapy, some clients became panicky, others were horrified at the thought of the perpetrator being in the room, and

https://doi.org/10.1037/0000336-003 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  33

34  Emotion-Focused Therapy for Complex Trauma

still others refused to participate. Subsequent client participation in IC required exploring and addressing these difficulties. For example, when the client Monica, whose mother had committed suicide, was asked to imagine her mother sitting in an empty chair, Monica became panicky, clutched at her blouse, and had difficulty breathing. The procedure evoked the pain and horror of finding her dead mother. Interventions helped her manage this distress while at the same time confronting her imagined mother with the pain and resentment she felt about that suicide. Other processes that consistently emerged for clients dealing with child abuse trauma were shame and self-blame about the trauma, which frequently manifested as depression. Working through these issues was a key component of therapy with Monica: Although she had not been abused, per se, she felt “tainted” by her mother’s “atrocity,” feared that she and her siblings were somehow to blame for her mother’s suicide, and felt that she could not have been important to her mother to have been abandoned and traumatized so horrifically. Interventions helped her work through this shame and her fears and longing for assurance that she had been loved. It also was observed that clients in the “unfinished business” study (Paivio & Greenberg, 1995) who were dealing specifically with childhood abuse did not want to express vulnerable feelings, such as sadness, to imagined others who were perceived to be cruel and abusive. In these instances, effective work with these emotions involved clients disengaging from the IC procedure and instead expressing these feelings to the therapist, who was able to provide the necessary compassion and support. Vulnerable feelings were expressed during IC to those imagined others who were perceived to be capable of responding compassionately. In the case of Monica, although she felt abandoned and betrayed by her mother, she did not perceive her mother to be cruel or abusive and was able to express her pain and sorrow directly to her imagined mother using the IC procedure. She was able to do this more fully after expressing her anger about the devastating impact her mother’s actions had had on her and her family. In instances of client refusal or inability to participate in the IC interventions, Paivio et al. (2010) developed and evaluated an alternative, less stressful “evocative exploration” procedure in which clients imagine perpetrators in their “mind’s eye” and discuss all material in the context of the therapeutic relationship. Converging research suggests that while the physical enactment of an imagined confrontation offers some unique advantages, the essential aspect of this work is the sequence of emotional processing steps that the intervention maps out. Finally, two different pathways to resolution were observed for clients deal­­ing with childhood abuse. First, for some clients, increased acceptance of and warmth toward offenders, particularly those who were primary attachment figures, was an important outcome. For Monica, healing the relationship with her internalized mother was a primary goal of therapy. Resolution involved holding her mother accountable for the harm she had caused and then

The EFTT Treatment Model 35

imagining that her mother would be remorseful and take full responsibility for that harm. Monica thus was able to forgive her mother. Other cases presented a slightly different pathway to resolution. Although clients resolved issues with offenders at the end of therapy, they typically did not feel more accepting and forgiving. This was particularly the case when the offender was seen to be cruel and unrepentant. In these instances, the client felt more detached from the other, who was still perceived as despicable but was now seen as less threatening and perhaps “sick” or pathetic. The suitability of each of these pathways toward resolution is not prescriptive; preference for one or the other becomes apparent over the course of treatment and is entirely based on the client’s idiosyncratic processes and interpretations. Ongoing development of EFTT is based on observing client difficulties with standard EFTT procedures. These included emotion dysregulation and anxiety, as well as poor capacity to attend to emotional experience. Both these difficulties interfere with engagement and exploration of painful internal experiences and with a client’s general capacity to access the healthy adaptive experiences essential to emotional transformation and personal change. The following section presents the theoretical foundations of the EFTT treatment model.

THEORETICAL FOUNDATIONS EFTT is an integrative approach that is grounded in current theory and research on emotion-focused therapy (e.g., Greenberg & Goldman, 2019a; Greenberg & Paivio, 1997; Paivio & Greenberg, 1995) and shares features with behavioral (e.g., Hembree & Foa, 2020), cognitive behavioral (e.g., Jackson et al., 2020), and attachment-based psychodynamic approaches (e.g., Fosha, 2021; Fosha & Thoma, 2020) to the treatment of trauma-related disturbances. However, EFTT is part of a long tradition of experiential therapies and provides an overarching theory that integrates aspects of these other treatments within this broader experientially oriented framework. General Theory of Functioning The general emotion-focused theory of healthy human functioning draws on the principles of attachment, experiential therapy, and emotion theories. These principles are delineated in the following sections. Emotion-focused therapy emphasizes the centrality of early attachment experiences in the development of self and the expectations of others. From a humanistic therapy perspective, this has its origins in Rogers’s (1980) view of the importance of unconditional positive regard in self-development. This approach lays specific emphasis on the developmental importance of affective experiences in attachment relationships. Accordingly, healthy attachment relationships provide a sense of safety and security that fosters exploratory

36  Emotion-Focused Therapy for Complex Trauma

behavior, a sense of self as worthwhile and competent, and a sense of intimate others as supportive and trustworthy (Bowlby, 1988). In addition, through appropriate emotion socialization and coaching from attachment figures (Gottman, 1997), children learn to regulate and make sense of emotional experiences and soothe themselves in times of distress. This learning takes place in caregiver–child conversations that involve narrative-emotion processing of important life experiences. In turn, narrative processes have a central role in the development of ones’ identity (Paivio & Angus, 2017). Theory of Dysfunction Specific to Trauma The theoretical concepts discussed here are particularly relevant to the area of trauma. The EFTT view of trauma-related dysfunction is based on material presented in the preceding chapter. In brief, first, basic trauma theory states that unresolved traumatic experiences are encoded in right brain experiential memory and activated in response to current stimuli that resemble the trauma (van der Kolk & McFarlane, 1996). This is evident, for example, in reexperiencing symptoms (e.g., nightmares, flashbacks) of posttraumatic stress disorder (PTSD). Second, repeated exposure to trauma at the hands of caregivers has particularly devastating effects. These experiences can result in negative self–other representations that continue to influence current self-concept and close interpersonal relationships. Third, complex trauma in early development has a particularly detrimental effect on the development of emotional competence, particularly emotion regulation capacities. The fear response to threatening stimuli (i.e., fight, flight, freeze; LeDoux, 2012) becomes more generalized and entrenched, resulting in chronic nervous system overactivation. Children learn to shut down to regulate their distress, relying on avoidance to cope with the painful, powerful, and confusing feelings generated by these experiences. When experiential avoidance is chronic, it is associated with several disturbances, including substance abuse, self-injurious behavior, interpersonal problems, and impoverished social support (Hayes et al., 2012). Moreover, chronic avoidance is thought to perpetuate trauma symptoms, interfere with recovery, and contribute to immune system breakdown (Foa et al., 2019; Pennebaker & Chung, 2011). Other problems with emotion competence are related to impairments in perceptions of emotional experience. Starting in childhood, people with a history of physical abuse, for example, are not simply hyperreactive, nor do they have sweeping response biases. Rather, these individuals typically perceive the emotional cues of anger and fear faster and with better acuity than those who have not suffered abuse (Ford, 2020). At the same time, however, children with histories of trauma seem to lag in the speed and confidence with which they can identify expressions of sadness (Pollak & Sinha, 2002). Individual differences in emotional perception such as these have real-time implications for using evocative interventions within the session. This is an important consideration for therapists who want to help their clients make sense of their emotional reactions.

The EFTT Treatment Model 37

Clinical observations and empirical studies have shown that a wide range of emotional experiences and reactions are associated with trauma and PTSD (see Power & Fyvie, 2013). Acknowledgment of this broader range of emotional experiences in our field is reflected in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) removal of PTSD from a section on anxiety disorders and inclusion in a newly created section on trauma and stress-related disorders. Moreover, the newly included “alterations in cognitions” symptom cluster of PTSD now makes explicit a range of emotional processes besides anxiety, including anger, guilt, and shame. Unfortunately, many exposure-based approaches for working with trauma continue to be strongly aligned with a partly outdated understanding of PTSD as an anxiety disorder and still focused on extinguishing fear. Now more than ever, there is a need for more comprehensive experiential and emotionfocused approaches to working with trauma. Theory of Change in EFTT The two posited global change processes in EFTT are providing a safe therapeutic relationship and processing trauma memories. In terms of the therapeutic relationship, a fundamental assumption underlying most experiential therapies is that therapist compassion, genuineness, and empathy are necessary (if not sufficient) ingredients for change. In EFTT, the relationship functions in two ways to promote change. First, an empathic and collaborative therapeutic relationship supports client engagement in reexperiencing procedures. In this sense, the relationship is the sine qua non medium that allows for other change processes. Second, this relationship quality helps counter the empathic failures of previous attachment relationships. Experiences of safety and support are internalized, promote self-development and interpersonal trust, and generalize to other relationships, thereby helping to restore the capacity for interpersonal connectedness that was disrupted by trauma. Thus, EFTT shares features with both cognitive behavior therapy (relationship as “anesthetic”) and relational psychodynamic (relationship as directly curative) perspectives on the functions of the therapeutic relationship. The second posited change process in EFTT is emotional processing of trauma memories. Most trauma experts agree that recovery from trauma requires reexperiencing trauma feelings and memories in a safe environment so that information is available for emotional processing—that is, exploration and modification through the admission of new information (Foa et al., 2019). From a behavioral perspective, emotional processing primarily involves desensitization processes such that individuals learn that they can tolerate trauma material without being destroyed by it. From an EFTT perspective, emotional processing involves a more complex set of processes that are explicated in Chapter 3. In general, emotional processing of complex trauma involves not only desensitization to painful feelings and memories but also active construction of new idiosyncratic meaning—that is, a more adaptive and coherent view of self, others, and traumatic events. Processing of trauma memories

38  Emotion-Focused Therapy for Complex Trauma

also requires the application of rational and linguistic processes to trauma material that is encoded in the experiential system but has remained un­processed or has been processed incompletely. An indicator of resolution, therefore, is that client narratives about traumatic experiences become more coherent, personal, affectively focused, and self-reflective. These qualities are reflected in the construct of experiencing, which is the focus of Chapter 5. In sum, affective and narrative disruptions are at the core of disturbances stemming from interpersonal developmental trauma, and EFTT is exceptionally well suited to address these difficulties. Clients learn to rely on interpersonal support so that they can tolerate previously avoided material and develop a more adaptive understanding of self, others, and traumatic experiences. These features of EFTT theory are consistent with other well-established therapies for adult survivors (see Ford & Courtois, 2020). However, EFTT also makes several distinct contributions to the conceptualization and treatment of complex traumatic stress disorders.

DISTINGUISHING FEATURES OF EFTT The following subsections outline the features that are characteristic of EFTT and distinguish it from other approaches. Focus on Health and Adaptive Resources Although EFTT includes attention to modifying maladaptive emotions, such as fear and shame, it explicitly emphasizes client strengths and resilience, as well as accessing previously inhibited adaptive emotions. Again, accessing anger at violation helps to counteract powerlessness, victimization, and selfblame, whereas experiencing sadness accesses compassion for self and self-soothing capacities that aid in grieving losses and moving on. EFTT interventions direct clients’ attention to these adaptive emotions and associated resources. This emphasis on adaptive resources is consistent with the burgeoning interest in the concept of trauma resilience (Harvey et al., 2003). Psychopathology and resilience are not mutually exclusive. Furthermore, recovery involves using strengths in some domains to help in others. To this end, it is important to identify the resilience capacities of individuals early in the recovery process and use these to promote recovery. Harvey et al.’s (2003) study found that factors such as connections with others over time, group membership, success experiences (e.g., work, parenting), self-care, and attributions of responsibility or choice were associated with client resilience. EFTT interventions explicitly highlight and direct clients’ attention to these and other personal strengths and resources as a way of strengthening the self. Reliance on Therapist Empathic Responding All effective psychological treatments rely on therapist empathic attunement to client feelings and needs. This is the basis for treatment goals. However,

The EFTT Treatment Model 39

experiential approaches have paid particular attention not only to attunement but also to advanced empathic responding and have developed a taxonomy of empathic responses and associated functions (Watson, 2019). Empathic responding to client feelings and needs is the primary intervention used throughout EFTT. This is used particularly to address the emotion regulation deficits described in the preceding chapter that are so central to complex trauma. Accordingly, accurate empathic responses can enhance the emotion regulation capacities identified by experts on child emotion development (Gross, 2015); that is, they help clients to access, identify, and accurately label the full range of emotions and associated meanings, modulate the intensity of emotion (upregulate and downregulate), and teach appropriate emotional expression. Imagery and Enactments In trauma work, techniques also are required that access experiential memory and promote the processing of intense emotion. Interventions that involve emotion and somatic and sensory activation foster this type of right-brain, bottom-up processing (i.e., it is grounded in specific sensory experience compared with top-down processing, which is based on general conceptual knowledge). EFTT draws on a long experiential and humanistic tradition and well-developed technology for overcoming experiential avoidance, evoking affective experience, and promoting experiential awareness. These, coupled with verbal symbolization, can help reverse the effects of trauma. Evocative empathy, experiential focusing, and gestalt-derived procedures involve imagery and multimodal enactments that quickly evoke core processes (i.e., trauma material encoded in experiential memory), making them available for exploration, integration, and change. Imagery techniques are newly emphasized in this volume in the context of memory work and reexperiencing procedures (Chapter 7). Marker-Driven and Process-Directive Intervention A major contribution of emotion-focused therapy to the treatment literature is the idea of marker-driven intervention. This involves identifying different types of emotions and associated processing difficulties (Goldman, 2019; Greenberg & Paivio, 1997) as in-session markers for initiating specific therapeutic interventions. This “if–then” approach proposes that, within the broader context of understanding a particular case, “if the client presents marker X, then the therapist should do intervention Y.” In the interventions discussed in later chapters, facilitating moments of productive process in this way are themselves considered “mini-outcomes.” These include, for example, accessing primary adaptive emotions, exploring and changing maladaptive emotions, and resolving complex difficulties, such as self-criticism or attachment injuries. These difficulties cut across and are more informative than global diagnostic categories in terms of intervention. For example,

40  Emotion-Focused Therapy for Complex Trauma

unresolved attachment injuries and self-critical processes can be at the root of either PTSD or major depression, but not all clients with PTSD have attachment issues, and not all major depressions are generated by selfcriticism. The emphasis on moment-by-moment processes has resulted in exceptionally specific and well-articulated guidelines for implementing interventions (see Greenberg & Goldman, 2019a). EFTT draws on these guidelines. EFTT therapists make use of an ongoing process diagnosis, in which they monitor and attend to the client’s unfolding affective state and level of readiness for potential interventions. Being familiar with the client markers of especially productive modes of processing moment by moment can help orient therapists to a client’s emerging patterns of change (Pascual-Leone, 2009). Moreover, these markers can help therapists with process-based choices for intervention and answer questions such as “The client has already superficially identified an emotion and keeps going in circles; what might help her go deeper?” “When the issue arises, would it be more productive to help the client explore the subjective experience of a transgression or the motivation of the perpetrator?” and “The client makes progress but then always ends up feeling hopeless; is this productive?” By increasing their awareness of client shifts in experience and familiarizing themselves with productive patterns of processing, therapists can increase the precision of their interventions. These are the skills required to effectively use the process models that are the basis of EFTT (e.g., the steps in the process of resolving attachment injuries, described in Chapter  6). These models, in turn, act as maps to guide intervention and move the client closer to resolution. Focus on Resolving Issues With Particular Attachment Figures Many treatments for complex trauma focus on skills development and changing current self-related and interpersonal problems (e.g., Ford & Courtois, 2020). Even relational psychodynamic models identify maladaptive inter­personal patterns and provide a corrective experience with the therapist to change these patterns (e.g., Lowell et al., 2020). EFTT, in contrast, concep­tualizes the adult disturbances associated with childhood maltreatment as largely involving unresolved issues with specific individuals, typically attachment figures. Clients not only are distressed by current difficulties but also continue to be distressed by powerful unexpressed feelings, unmet needs, and disturbing memories concerning these individuals. From an attachment perspective, they are unable to separate, let go of unmet needs, and move on until feelings are expressed and processed and past experiences are satisfactorily resolved. The client Monica, for example, was plagued by feelings of confusion, shame, and anger about abandonment and unmet needs for “mothering” her entire life. The IC procedure used in EFTT is designed to resolve issues with these specific individuals. Together with the therapeutic relationship, resolving these issues is analogous to transforming internal object relations— that is, changing internal representations of the self in relation to attachment

The EFTT Treatment Model 41

figures. This generalizes to other relationships and increases the capacity for interpersonal connectedness. Empirical Support Although there are a few stand-alone outcome studies supporting individual therapies for complex trauma (e.g., Ford & Courtois, 2020), EFTT is the only treatment of this type based on a systematic program of process and outcome research that spans 30+ years. As noted in an earlier section, EFTT developed from an empirically verified process model of resolving unfinished business with significant others using an empty-chair technique (Greenberg & Foerster, 1996; Greenberg & Malcolm, 2002) that is the basis for the IC procedure. Specified steps in this process that empirically discriminated clients who resolved interpersonal issues from those who did not include expression of adaptive emotion and associated needs, entitlement to unmet needs, and changed perceptions of self and others. Clients who resolve these issues shift to a stance of increased self-empowerment and self-esteem, develop a more differentiated perspective of target others, and appropriately hold them (rather than themselves) accountable for harm. An early outcome study (Paivio & Greenberg, 1995) supported the efficacy of individual therapy based on the model with a general clinical sample. Clients made large gains in multiple domains that were maintained at follow-up. The sample included a subgroup of clients dealing with child abuse issues. Subsequent analyses of 72 sessions of therapy with these individuals led to the development of EFTT specifically for resolving child abuse trauma. Refinements to the original model included more attention to secondary issues of avoidance and self-blame, a longer course of therapy to address these issues, and reframing the empty-chair intervention to emphasize exposure-based and interpersonal processes. The term imaginal confrontation was adopted because it better captured this emphasis on trauma-related processes. Outcome research supports the efficacy of EFTT with IC (Paivio & Nieuwenhuis, 2001), whereas process–outcome research supports the therapeutic relationship and emotional engagement with trauma material during IC as mechanisms of change (Paivio et al., 2001). A clinical trial (Paivio et al., 2010) evaluated two versions of EFTT—one with IC and the other with the new evocative exploration intervention that did not involve chair-work. (Both procedures are presented in depth in Chapter 6). Results indicated that clients in both conditions made large and clinically significant gains on multiple dimensions, and these were maintained at 1-year follow-up. The average pre–post effect size across 10 dependent measures, which included symptom distress (PTSD, depression, anxiety), self-esteem, interpersonal problems, and resolution of issues with specific abusive and neglectful others, was 1.3 standard deviations. This far exceeds the American Psychological Association’s recommended criteria (0.8 standard deviations) for effective therapy. Importantly, these results also identify an additional, less stressful effective treatment alternative for this client group.

42  Emotion-Focused Therapy for Complex Trauma

Broad Applicability Across Gender, Severity, and Type of Abuse EFTT (Paivio et al., 2010; Paivio & Nieuwenhuis, 2001) was the first evidencebased individual therapy for both men and women who are dealing with different types of child abuse trauma (emotional, physical, sexual). Before the development of EFTT, published studies were almost exclusively group approaches for women with histories of child sexual abuse (e.g., Morgan & Cummings, 1999; Saxe & Johnson, 1999). Later, a handful of published studies evaluated individual therapy (e.g., Chard, 2005; Cloitre et al., 2002; Resick et al., 2003), but these again focused almost exclusively on women with histories of child sexual abuse and a diagnosis of PTSD. However, the literature presented in the preceding chapter on the prevalence of childhood maltreatment and associated disturbance indicates that experiences of maltreatment are not unique to women or confined to sexual abuse experiences. Furthermore, many individuals who have experienced complex and cumulative trauma seek therapy for a variety of disturbances besides PTSD. EFTT addresses a constellation of trauma-related disturbances common across men and women and multiple types of maltreatment experiences. One issue in treating clients with histories of multiple traumatic experiences concerns identifying which event is most productive to focus on in therapy. EFTT makes this decision in collaboration with the client. At the beginning of therapy, clients are asked to identify the type of abuse experiences and abusive or neglectful others that are most troubling and that they want to focus on in treatment. The protocol is sufficiently flexible to address individual client processes and treatment needs, and in the end, resolution of these core issues generalizes to current areas of functioning. When discussing the applicability of EFTT, it is worth reiterating material on indicators and contraindicators presented in the Introduction to this book. The standard EFTT treatment model presented in the following pages is a short-term (16–20 sessions), trauma-focused approach. As such, it is suitable for clients with some capacity for emotion regulation and to focus on circumscribed traumatic event(s) from the past. For clients with severe affect dysregulation who engage in ongoing self-harm behaviors and with comorbid disturbances (e.g., substance abuse), the standard model presented here will need to be modified. Aspects of other treatment approaches (e.g., skills training) that address these client difficulties can be integrated into a longer course of therapy. Alternately, aspects of EFTT can be integrated into other approaches when clients are ready for emotional activation and exploration.

DISTINCTIONS BETWEEN EFTT AND THE GENERAL MODEL OF EMOTION-FOCUSED THERAPY It is useful to identify the features of EFTT specifically for trauma that distinguish it from the general model of emotion-focused therapy (Greenberg & Goldman, 2019a) and other current experiential therapies. As noted earlier,

The EFTT Treatment Model 43

these distinct features emerged in the context of therapy with a subset of clients (including Monica) who were dealing with complex trauma. These distinct features derive from several sources, including the nature of the population and problems that therapy was designed to address, the research context in which the approach was developed, and a deliberate emphasis on integrating the guidelines and strengths of other approaches to the treatment of trauma (e.g., Ford & Courtois, 2020). To begin, Elliott et  al. (2004) specified the tasks that are prototypical of emotion-focused therapy in general. The following tasks are particularly relevant to trauma work in EFTT. First, empathy-based tasks include communicating compassion for client struggles and suffering, understanding emotional meaning, and paying specific attention to markers of vulnerability (e.g., fear and shame about the emerging experience) that frequently emerge in therapy with this client group. Second, relational tasks include attention to attachment issues that are the sources of disturbance (e.g., feelings of worthlessness, insecurity, distrust) and addressing client anxiety about the therapy process. The latter partly can be accomplished by validating clients’ anxiety, providing information about trauma response and recovery, as well as clear expectations about therapy processes and client and therapist roles. Relational tasks also include monitoring and addressing client difficulties with other types of tasks used in therapy (e.g., experiencing, enactments). Third, experiencing tasks generally involve helping clients explore the meaning of affective experience. This can be particularly challenging for many trauma survivors who have difficulties identifying and labeling feelings (alexithymia) and have learned to rely on avoidance as a coping strategy. Specific experiencing tasks, therefore, frequently include directing clients’ focus of attention when they are confused, overwhelmed, blank, or numb; when they present with feelings that are unclear or abstract; or when they are externally focused on situations or behavior. Experiencing tasks are also appropriate when clients have difficulties answering questions about and identifying and exploring feelings and their meanings. Fourth, reprocessing tasks in EFTT that involve revisiting trauma feelings and memories can be particularly terrifying, painful, and difficult. This can include not only experiencing horrifying images and physical pain but also reexperiencing oneself as unloved, worthless, dirty, or negligible and attachment figures as malevolent. Thus, EFTT focuses on intensely frightening and painful experiences to an even greater extent than emotion-focused therapy for other client problems. This edition contains a new chapter (Chapter 7) focused specifically on memory work and reexperiencing procedures in EFTT. Memory work is also an important and sometimes preferred alternative to two-chair dialogues for changing attachment-based shame and self-critical processes. EFTT specifically integrates information on narrative processes drawn from research on narrative-emotion processes (Paivio & Angus, 2017) that are observable in cases of trauma (e.g., storytelling that is void of emotion or coherent content as observed in dissociation). The content and quality of

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client narratives about traumatic experiences are central to all trauma therapies, although they typically have not identified narrative markers to guide clinicians in choosing corresponding clinical interventions. Reexperiencing interventions, which also characterize trauma therapies, helps clients to productively re-narrate and reprocess traumatic experiences. EFTT draws on the vast literature about productive trauma narrative reprocessing. Importantly, EFTT specifically focuses on reducing client avoidance of trauma feelings and memories (Chapter 8) typical of therapy with traumatized clients—clients have difficulties approaching and allowing threatening and painful experiences and participating in evocative interventions. EFTT also may be more structured and content directive than emotionfocused therapy for other presenting concerns. For example, therapists deliberately instruct clients to disclose trauma memories rather than simply respond to markers of their emergence. Therapists also may make connections between current concerns and past situations that could be considered interpretations and use confrontation, for example, to address maladaptive behaviors. Moreover, therapy frequently includes management strategies for clients with severe affect dysregulation problems or who engage in self-destructive behaviors, such as substance abuse or self-injury. In part, this more directive style results from the fact that clients suffering primarily from trauma frequently need more explicit support. The extra support they need includes being educated about trauma, explicitly oriented to the moment-by-moment processes at hand, and clearly instructed in the engagement of tasks when working with emotion. Although they may not object, a purely discovery-oriented or Rogerian approach can be unnerving for these clients, and they benefit from a therapist occasionally offering explicit signposts of orientation and instruction in how to use experiential tasks. This is increasingly the case for clients who have been more severely traumatized or who have comorbid personality disorders.

THE TREATMENT MODEL EFTT is a semistructured approach that typically consists of 16 to 20 weekly 1-hour sessions. However, the exact length of therapy is based on individual client processes and treatment needs. In cases of greater severity and duration of trauma, as well as repeated victimization, therapy likely will be more long term. Specifically, more time could be required to establish safety and trust, reduce dissociation and maladaptive avoidance, and develop more effective emotion regulation capacities. In our most recent work with refugee trauma survivors, EFTT included more supportive and present-focused work on identity and adjustment issues. Phases and Tasks of EFTT EFTT is not a stage or linear model, but specific processes typically are dominant during specific phases of therapy. Clients can circle through aspects of all

The EFTT Treatment Model 45

phases in a single session and vary the time needed to progress through individual phases. In short, clients move through the phases of therapy in a dynamic and reiterative process, progressing “two steps forward, one step back” (Pascual-Leone, 2009). This nonlinear progression of clients through the phases of treatment has been empirically demonstrated through the observation of clients, both moment-by-moment and cumulatively, over an entire treatment (Pascual-Leone & Kramer, 2019). Phase 1: Cultivating the Alliance The first three sessions of EFTT are exclusively devoted to cultivating a secure attachment bond, collaborative case conceptualization that includes assessing client emotional processing difficulties and collaborating on the goals of therapy and how these will be achieved. A secure attachment bond is primarily created by establishing client safety and trust. Safety and trust, in turn, are fostered by communicating genuine compassion for clients’ past and current suffering and their struggle to cope (e.g., the therapist might say, “It’s terrible that a child be exposed to such ugliness. I feel bad that you had to go through all that, especially alone”) and empathically responding to painful feelings and needs for comfort, control, justice, and so on. This will foster further disclosure and begin to reduce isolation. Collaboration involves clients agreeing on the importance of reexperiencing trauma feelings and memories and understanding how this will help them accomplish their goals (e.g., to be free of trauma symptoms and emotional baggage, change maladaptive behavior, feel better about self, have healthier relationships). The rationale for memory work and a focus on feelings must be tailored to the individual client’s goals and treatment needs. Resolving interpersonal injuries related to childhood maltreatment is the primary task of therapy, and IC is the procedure most frequently used to accomplish this. Successful task collaboration during the initial IC requires monitoring the client’s capacity to regulate emotions and engage with trauma material and the procedure. For example, Monica entered the third session complaining about yet another incident in which she wished her mother could have been available for support but was not. This was an ideal marker for asking Monica to imagine her mother in the empty chair and tell her about her resentment. This evoked panic and difficulty breathing. The therapist empathized with Monica’s vulnerability and distress, coached her in breathing, and invited her to disclose what was going on (to reduce isolation and fear). Monica disclosed horrifying images of all the blood, trying to wake her dead mother, and her mother in the coffin, as well as more detailed accounts of the circumstances surrounding these events. The therapist provided a brief rationale for engagement in IC and collaborated with Monica on a strategy for engaging in the procedure without the visual imagery. The therapist provided guidance, reassurance, and support throughout the process. For clients who cannot or will not participate in IC, intervention can switch to processing material exclusively in interaction with the therapist. The important point is to continue to focus on trauma material and follow the steps

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in the model of resolution. This is discussed further in Chapter 6. The introduction of IC and activation of core processes mark the transition from the early to the middle phases of EFTT. Phase 2: Reducing Fear, Avoidance, and Shame The second or middle phase of EFTT focuses on reducing self-related processes that are barriers to resolving relational trauma and attachment injuries. These processes include lack of clarity about internal experience, fear and avoidance of affective experience, and self-criticism and self-blame. Once safety is established in Phase 1, the explicit reexperiencing of specific trauma memories and feelings helps clients tolerate, process, and make sense of those experiences. In turn, this facilitates the development of more adaptive interpretations of self, others, and events. Self-related problems also frequently include depression or anxiety and the associated core sense of self as vulnerable, insecure, or defective. For example, Monica feared she would be judged by others and stigmatized because of her mother’s behavior, and this became her “ugly secret.” She also felt victimized and deficient. Other clients have internalized a “bad parent” such that these become self-inflicting intrapsychic processes. Two-chair dialogues, experiential focusing, and evocative exploration are used in conjunction with IC to explore and resolve these difficulties. Interventions are aimed at strengthening the client’s sense of self by accessing alternative healthy internal resources (self-protection, self-soothing) and changing maladaptive avoidance behavior. Phase 3: Resolving Trauma and Attachment Injuries The late phase of EFTT focuses on resolving issues with specific abusive and neglectful others and involves accessing adaptive anger and sadness and associated meanings. For clients like Monica, this takes place in the complex context of grieving traumatic losses that had been interrupted. Her profound anger at having been traumatized and abandoned and the years of chaos, suffering, and responsibility had never been validated and continued to eat away at her. Therapeutic goals included the expression and validation of her anger, allowing her anger to run its course, and the full experience and expression of sorrow and grief. The uninhibited experience and expression of adaptive emotion is the catalyst for resolving traumatic attachment injuries in the last phase of therapy. As avoidance and self-blame are reduced, clients gradually are better able to confront imagined abusive and neglectful others. Interventions encourage the client to articulate the full impact of the abuse on them. It also is critical to elicit the imagined perpetrator’s response to the client’s confrontation. This captures the client’s view of the other’s capacity for understanding, empathy, and regret. For example, over time, Monica came to believe that her mother would profoundly regret what she had done and take full responsibility for the harm she had caused. Enacting her mother elicited assurance in this role that she had been loved and accessed memories of happy times and loving

The EFTT Treatment Model 47

interactions with her mother (e.g., she remembered brushing her mother’s hair). In response, Monica stated that she felt warm and loved for the first time since her mother died. One goal is for clients to arrive at a more differentiated perspective of abusive and neglectful others. In cases like Monica’s, the other (in this case, her mother) is seen as more complex and human. If the client can see the other as repentant, the client is able to feel more compassionate and loving toward the person. In alternate cases, the other may be perceived as pathetic and incapable of understanding. Either way, the offending others are perceived as more life sized and less powerful. Having the client enact or imagine the other also can elicit client empathic resources—for example, Monica sensing some of the desperation her mother must have felt. This can be particularly important in healing attachment relationships—for instance, coming to understand that one or both her parents also were victims or had limited resources. This final phase of EFTT also includes issues related to therapy termination. In the last few sessions, a final IC is introduced to complete resolution as much as possible and assess and consolidate changes. Clients are asked to compare their current experience of imagining the perpetrator(s) with their experience during the initial dialogue. For example, Monica shifted from feeling tied up in knots, victimized, and deficient to viewing herself as a strong survivor. She also shifted from the angry rejection of her mother and seeing her mother as superficial and self-centered to viewing her with compassion. She came to see her mother’s suicide as an act of desperation, a terrible, tragic mistake that her mother would undo if she could. Therapy termination also involves processing the client’s experience of therapy (difficulties, successes, helpful aspects) and mutual feedback. Discussions also focus on and support the client’s plans and goals for the future. Basic Intervention Principles (Therapist Intentions) Intervention principles are like therapist intentions that can be realized through several response modes, including empathic responses, questions, directives, and so on. EFTT intervention principles most frequently used throughout therapy include the following (examples in parentheses are the therapist’s responses): • Evoke autobiographical memories (e.g., “Do you remember a time when . . .?” “Let’s go back to that time. . . . Bring it alive for me”). Evoking episodic memories of distressing and painful events deepens client emotional engagement in any therapeutic task because they activate emotion schemes. Moreover, this is the heart of trauma work. Chapter 7 focuses on the deliberate exploration of distal (trauma) or recent memories of troubling situations in which the core maladaptive sense of self was formed or activated as a separate stand-alone task. • Direct client attention to and expression of internal experience (thoughts, feelings, bodily sensations) using simple reflections (e.g., “That must have been

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so painful”), questions (e.g., “What was going on for you on the inside?”), or directives (“Pay attention to your body as you speak about this”). • Modulate emotional intensity, reducing it through empathy, validation, and reassurance or increasing intensity through evocative empathy (e.g., “You must have been so starved for attention,” “How dare he!”), directives (e.g., “Say that again/louder”), or imagery or enactment techniques (“What is the look on her face?” “So, you stop yourself from speaking up, muzzle yourself. Do it, put your hand over your mouth”). The arousal of emotion needs to be modulated for emotional schemes to be optimally activated without the client being overwhelmed. • Verbally symbolize the meaning of emotional experience (e.g., “So the worst part about that was . . .?” “There is something so important about that”). Helping clients make sense of painful emotional experiences is the foundation of emotional processing and optimal learning. • Establish intentions, desires, wants, and needs (e.g., “What you needed as a child was . . .”; “So, you are no longer willing to put up with . . .”; “What is most important to you is . . .”). This increases awareness of goals, core values, and standards that enhances motivation for change. • Affirm the client’s sense of vulnerability and uncertainty (e.g., “I know how difficult it is to get in touch with those memories. Take your time; you’re doing fine”). Empathically acknowledging how vulnerable and unsafe clients feel when approaching painful, shameful, fearful experiences reduces anxiety and their sense of aloneness. Responding to client vulnerability is essential before one embarks on exploring painful experiences. • Validate perceptions and experience (e.g., “Of course,” “No wonder,” “This is another part of the damage that was done”). These responses are intended to normalize client experience and, like affirming vulnerability, reduce anxiety so that internal experience can be explored. In memory evocation, the important features of productive memories are that they are specific, autobiographical, affective, and sensorial (Paivio & Angus, 2017). This is relevant to research and theory supporting the encoding of trauma material in experiential memory (e.g., van der Kolk, 2015). From this perspective, specific and detailed memories of the concrete features of real auto­ biographical events provide more alternatives for further processing than general abstract memories. Self-related (autobiographical) and affectively charged events are more memorable because they elicit more attention allocation and increased sensory experience. Working with memories in this way allows them to be reconsolidated as revised experiences. This is discussed further in Chapter 7 on reexperiencing trauma memories. Directing attention to internal experience, directing expression of experience, and exploring the meaning of experience are the “meat and potatoes” of experiential therapies. Directing attention is the foundation of all these intervention principles. Attentional processes are central in determining what

The EFTT Treatment Model 49

people experience and generating truly novel experiences and performance. Attending to new features of experience that previously were minimized or glossed over will produce new awareness and new meaning. By directing client attention and posing the right exploratory questions, new information becomes available. Bottom-up processing (i.e., attention to sensory–perceptual– emotional data vs. concepts) is more conducive to the discovery of new information compared with prior knowledge and expectations, which are more conducive to pattern recognition (Pascual-Leone & Greenberg, 2007). Novice therapists who overemphasize expression skills often neglect directing attention. However, authentic expression emerges from the inside, from attending to internal experience. Exploring meaning is a core process, and establishing intentions is a critical subset of this process. Responses explicitly highlight client wants, needs, desires, and longings (e.g., wanting so much to please or be treated with respect, starving for attention), as well as core values and standards and deepest concerns. When therapist responses do this, they reinforce clients’ motivation, promote growth, and help move the process forward. Specific Interventions and Procedures Several therapeutic tasks and specific procedures are discussed in detail through­out the book. Although these are specifically defined, it is important to use them flexibly rather than adhering rigidly to a given protocol or procedure. Being familiar with the underlying principles of specific interventions and the entire treatment allows therapists to initiate, modify, and sometimes switch or change tasks in a manner that remains consistent with the spirit of treatment and empirically derived guidelines. In what follows, we outline four of the primary tasks and procedures used in therapy. Empathic Responding Empathic responding is the primary intervention used throughout EFTT. It is used as an active and deliberate intervention, either alone or in conjunction with all other procedures. There is increasing recognition of the importance of “unflinching empathy” as the foundation of therapy with trauma survivors (Harrison & Westwood, 2009). Paivio and Laurent (2001) early on delineated how empathic responses are used in EFTT to cultivate the therapeutic relationship, reduce client avoidance and self-blame, and explore and resolve complex trauma. This formed the basis of the EFTT treatment model and is elaborated on in specific intervention chapters. Empathic attunement to client vulnerability and arousal levels is particularly critical in trauma therapy because of the risk of retraumatization. Furthermore, Paivio and Laurent (2001) specified the interrelated advantages of empathic responses in therapy for child abuse. First, empathic responding that mirrors or follows client processes rather than directing, teaching, or interpreting the client’s experience from an expert stance is minimally hierarchical, maximizes client control over the process, and thus increases the client’s sense of

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safety and control. Second, empathic responding ensures an accurate understanding of the client’s struggles, concerns, and goals that is essential for effective collaboration. Collaboration, in turn, additionally contributes to the client’s sense of safety and control. Third, empathic responses, by definition, communicate understanding, acceptance, and support and thus minimize the defensiveness that can be elicited by questions, challenges, and interpretations. Social anxiety and fear of negative evaluation are common among child abuse survivors, and this aspect of the therapeutic relationship provides corrective interpersonal experiences. Fourth, empathic responses (that are appropriately tentative), unlike direct questions or directives, implicitly teach accurate labeling and description of emotional experience. As noted in the previous chapter, the use of language is thought to be essential to the integration of traumatic experiences (van der Kolk, 2020), and many individuals with a history of child abuse lack these skills. Fifth, empathic responding models emotional authenticity, openness to experience, and compassion, which helps minimize the anxious self-monitoring commonly observed among child abuse survivors and increases the capacity for spontaneity. Finally, by responding empathically, therapists allow themselves to be touched by the client’s pain without being overwhelmed by it, thereby modeling effective emotion regulation and increasing intimacy and trust. In addition to these advantages, three interrelated functions of therapist empathy contribute to client emotional self-control and reprocessing of trauma material. These functions correspond to the criteria for healthy emotion regulation (Gross, 2015) described in the preceding chapter on trauma and are summarized next. Increase awareness and understanding of emotional experience. Empathic responses are a form of implicit emotion awareness training. Again, many survivors of child abuse have learned to be externally vigilant at the expense of attention to their internal experience and have difficulties recognizing and describing their feelings. Poor awareness of internal experience limits the individual’s capacity for emotional self-control. Empathic responses increase awareness by focusing attention on internal experience, helping clients accurately label feelings and articulate the meaning of emotional experience. The first way empathic responses contribute to self-awareness and emotion regulation is by focusing attention on client internal experience, communicating interest, and showing that the person and their feelings and perceptions are worthy of attention. This helps counteract the learned evaluation of one’s thoughts, feelings, wishes, and needs as bad, dangerous, invalid, or unimportant. Attending to internal experience also is necessary before one can exercise emotional self-control. Empathic responses that serve this function usually are brief statements made by the therapist that encourage the client to pay attention to a particular aspect of internal experience that could be adaptive (e.g., “That must have been so scary”) or maladaptive (e.g., “Sounds like you feel it’s not okay to be needy”).

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Teaching accurate labeling of emotional experience is the second major way empathic responses contribute to client awareness and effective emotion regulation. The capacity to verbally describe internal experience helps people make sense of their experience, which simultaneously reduces arousal and improves interpersonal connectedness. The therapist’s tentatively phrased empathic responses (e.g., “That must have been so humiliating”) again minimize the defensiveness, withdrawal, and shutting down that can be elicited by questions and directives. This is particularly so among clients who do not know what they are feeling (i.e., who are experiencing alexithymia) or who fear negative evaluation (i.e., social anxiety). The third way empathic responses contribute to self-awareness and emotion regulation is by helping clients symbolize or articulate the meaning of their emotional experience. Emotional meaning derives from the needs, concerns, perceptions, beliefs, action tendencies, memories, and images associated with one’s feelings. Empathic responses refer to these implied aspects of emotional experience, highlighting the gist, central concern, or most poignant aspect of what the client said (e.g., “So, what hurt so much was the idea that your own mother wanted to hurt you”). Empathic responses also invite elaboration (e.g., “Something about that look on her face . . .?”) and conjecture about client experience. For example, in response to a client’s description of his own passive– aggressive behavior, the therapist stated, “I guess you want to hurt her as much as she hurt you.” Empathic responses symbolize in language both adaptive (e.g., a need for comfort associated with sadness) and maladaptive aspects (e.g., self-critical thoughts that generate shame) of emotional meanings. Modulate emotion experience.  Empathic responses can both reduce and increase emotional intensity. They can reduce arousal by providing understanding, acceptance, and support. From a relational perspective, therapist empathy is the vehicle for establishing a secure attachment bond. Accordingly, painful and frightening feelings are easier to bear in the presence of an emotionally responsive attachment figure. This function of therapist empathy is particularly important when clients are reexperiencing trauma memories. Empathic responses that affirm the client’s vulnerability, cued by indicators of client fragility or embarrassment, can reduce anxiety about being judged and help the client allow and disclose painful and threatening experiences (Elliott et  al., 2004). Another important function of empathy is to validate or normalize experience. A response such as “Yes, I’m sure the last thing you want is to get close to those feelings that you’ve worked so hard to keep away” conveys understanding of fear, affirms the client’s emotional reality, and normalizes avoidance as a coping strategy. Therapist understanding and responsiveness are gradually internalized by clients, strengthening their capacity for self-soothing, self-support, and selfacceptance, which increases their capacity to manage intense emotion. Empathic responsiveness to clients’ feelings and needs also fosters interpersonal trust. Clients learn that they can rely on another person to help manage intense affect,

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which can generalize to relationships outside of therapy. Seeking social support when needed is a vital emotion regulation skill. Empathic responses not only help to reduce anxiety but also can be used to increase the intensity of emotional experience when needed. In the early phase of therapy, many clients will disclose horrendous episodes of abuse but are not experientially in touch with their feelings. Evocative words and phrases (e.g., “outraged,” “how dare he,” “tears you apart”) can heighten arousal and activate emotional experience and memories, making them available for exploration. Responses that refer to the client as a child can be particularly evocative. Evocative responses also can help to promote client entitlement to unmet childhood needs and thus foster self-empowerment (e.g., “insistence” on respectful treatment, “refusal” to accept maltreatment). Therapists also can use evocative empathy to exaggerate and thus increase awareness of the internal messages that contribute to anxiety, rage, shame, or emotional overcontrol. These processes can be explored in two-chair enactments. Responses such as “Somehow, if you remember what happened, you will die or go crazy” amplify rather than directly challenge the extremity of the client’s position. This can evoke a reaction in the part of the self that does not quite believe the catastrophic expectations. These reactions act as healthy internal resources that help the client manage and allow negative emotion. Finally, empathic responses used in conjunction with explicit intensification directives to “say that again” or “say it louder” can contribute to the effectiveness of these interventions. They ensure an accurate understanding of the client’s experience, model emotional intensity coupled with emotional self-control, and support intense emotional experience such as deep grieving (e.g., “So many tears . . . let them come”). Communicate feelings, meanings, and concerns appropriately. Empathic responses also implicitly teach communication skills. Difficulties identifying and communicating feelings (alexithymia) reduce the capacity for intimacy and leave people isolated and lonely. Similarly, the feelings of alienation frequently associated with traumatic experiences and PTSD are partly a function of difficulties communicating extreme experiences that are beyond the realm of most people’s experience. Empathic responses that model accurate labeling of feelings, verbal symbolization of meaning, and appropriately regulated affective material improve the client’s capacity to communicate and help restore interpersonal connectedness, first with the therapist and then outside the therapy session. Overall, therapist empathic responding helps enhance client capacities related to awareness, articulation, regulation, and reflection on the meaning of emotional experience. Empathic responses also will have a directional influence on whether emotion is subsequently activated (i.e., using evocativeness and upregulating arousal) or contained and soothed (i.e., downregulating arousal). This is partly done by purposefully selecting and facilitating the emotion processes essential for a given client and at a given moment. Productive client engagement in all EFTT tasks and procedures aims at processing traumatic experiences and facilitating change.

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Imaginal Confrontation Procedure The IC of abusive and neglectful others is the primary vehicle for resolving traumatic attachment injuries. Resolution and changed perceptions of self and these specific others generalize to other relationships. The IC procedure is introduced as early as possible in therapy (typically during Session 4) after establishing safety and trust in the therapeutic relationship. This quickly evokes core processes, including fear and shame, making them available for exploration. Therapist operations during IC have been delineated (Greenberg et al., 1993; Paivio et al., 2010) as follows: (a) promote psychological contact with the imagined other (e.g., vivid descriptions of the other, use of “I–you” language in dialogue with the imagined other), (b) evoke episodic memories associated with abuse, (c) explore and help clients overcome blocks to experiencing, (d) differentiate adaptive feelings (e.g., anger, sadness) and associated meanings from global distress and upset, (e) promote expression of unmet needs and entitlement to these needs (e.g., for protection, love, justice), and (f) explore shifting perceptions of self and imagined others. The therapist also maintains a balance between following the client’s moment-by-moment experience and directing the process. The IC intervention is used judiciously throughout therapy according to individual client processes and treatment needs. Results of the most recent clinical trial (Paivio et al., 2010) indicated that, on average, five sessions in a 16-session therapy contained substantial IC work, and this ranged from two to eight sessions. Imaginal Confrontation Without “Chairs” An alternative to using IC is the “evocative exploration” intervention, which was developed as a less stressful procedure for clients who are unwilling or unable to engage in the intended imaginal task. Like many reexperiencing procedures, imaginarily confronting perpetrators can be too evocative and activate trauma feelings and memories that are potentially overwhelming. Clients with a fragile sense of self (ego strength) may also prefer to maintain eye contact with the therapist rather than engage in a dialogue with an imagined other, and clients with performance anxiety may find it too anxiety provoking. Evocative exploration of trauma material is identical to IC, described earlier in terms of the model of resolution and intervention principles. Clients are encouraged to vividly imagine abusive or neglectful others and traumatic events in their “mind’s eye” and express their thoughts and feelings to the therapist rather than engage in a dialogue with an imagined other. Research findings support the view that this procedure is less stressful than IC. These findings and instructions for conducting the evocative exploration alternative are discussed further in Chapter 7 in the context of addressing client difficulties with the IC procedure. Memory Work and Reexperiencing Procedure A focus on memory work and reexperiencing traumatic events is central to trauma therapies and is presented as a new chapter in this volume. Trauma memories can spontaneously emerge in imaginal confrontations, evocative

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exploration, or other tasks and procedures, or they can be deliberately activated and explored as a stand-alone task. As a caveat, EFTT therapists never suggest to their clients that they may have suffered abuse in childhood when the client has no explicit memories of these events (i.e., it is poor practice to suggest there are repressed memories). Instead, therapists work with the memories (however limited) that a client presents to facilitate the client’s personal meaning for the present. The markers for memory work include the emergence of any memory of distal (trauma) or recent situations in which the core maladaptive emotion scheme and sense of self developed or is activated. Intervention can involve detailed sequential processing of the event or in-depth exploration of a particularly evocative fragment of a memory. The goals in both instances are to bring the experience alive, deepen emotional engagement, and access new adaptive resources to promote emotional transformation. Typically, both can be followed by imaginal confrontation of perpetrators and/or self-soothing to reduce self-blame and increase compassion for self. Chapters 7 and 9 present specific markers and guidelines for conducting both these types of memory work. Experiential Focusing and Two-Chair Enactments Other experiential procedures are used to explore and reduce self-related difficulties, such as confusion about internal experience, fear and avoidance of internal experience, and shame and self-blame. Guidelines for intervention have been clearly delineated elsewhere (see Greenberg & Goldman, 2019a). Focusing involves attention to and verbal symbolization of bodily felt or somatic experience. Two-chair enactments involve a dialogue between two parts of self—for example, the dominant self-critical part and the “experiencing” part that feels demeaned. The goals are to increase awareness of maladaptive processes and agency in contributing to bad feelings and to access alternative adaptive internal resources to challenge these feelings. The process of change involves explication and integration of these self-organizations. For clients who are resistant or reluctant to engage in imaginary dialogues, all interventions described earlier can be carried out exclusively in interaction with the therapist. It is the intervention principles that are important, not the specific techniques. The two constructs of emotional processing and experiencing are central to all the processes that are described in subsequent chapters. The following chapter focuses on the specific role of emotion, per se, in these processes.

3 Working With Emotion

I

n discussing emotion-focused treatments, one risks inadvertently conveying that emotion, per se, is the focus of treatment, which it is not. Emotion is perhaps best thought of as valuable insomuch as it is a vehicle for accessing implicit information and tacit meanings. Moreover, raw affect is only one aspect of experiential memory associated with trauma, along with thoughts, images, and somatic and sensory experiences. Exploring feelings and meanings (experiencing), not simply expressing emotion, is the primary source of new information and how new meaning is constructed in emotion-focused therapy for trauma (EFTT). In short, when it comes to therapeutic process—and this is true for all phases of EFTT—emotion is the means, and deeper experiencing (Chapter 5) is the ends. Nonetheless, we begin with emotion for a couple of reasons. First, as detailed in Chapter 1, emotion and emotional processes are central to complex trauma that involves the full range of emotional experiences, affective disruptions, and emotional processing as the primary mechanism of change. Second, emotions and emotional processes are obvious targets for trauma therapy—people come to therapy to change “bad feelings” and not to modify maladaptive cognitions or working models of self and others or construct new meaning. This chapter places EFTT in the context of current interests in affect and reviews fundamental concepts used throughout the chapters to come. Our goal in this chapter is not to present a comprehensive theory of emotion but to review key constructs in emotion-focused therapy in general (e.g., Greenberg

https://doi.org/10.1037/0000336-004 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  55

56  Emotion-Focused Therapy for Complex Trauma

& Goldman, 2019b; Greenberg & Paivio, 1997; Pascual-Leone & Greenberg, 2007) as they apply to complex trauma.

REVIEW OF EMOTION THEORY UNDERLYING EFTT The following subsections review key constructs and present a taxonomy of different types of emotion and associated emotional processing difficulties as well as intervention principles for addressing these difficulties. Moreover, we review subtypes of change processes that constitute the emotional-processing construct and inform productive intervention. The Role of Emotion in Adaptive Functioning First, the emotion system is an adaptive orienting system. Discrete basic emotions are associated with specific information. This includes specific neurological activity, expressive motor patterns, and dispositions for action that motivate specific goal-directed behavior important in survival. Thus, second, emotions are both action dispositions and motivators. Emotion also helps people survive by providing an efficient, automatic way of responding rapidly to important situations. It is well established that affect is processed faster and requires less mediation (fewer levels of processing) than cognition (LeDoux, 2012). Consequently, cognitive goals are given impetus by the orienting and action functions of affect. Third, emotions inform us about our priorities through their salience. Negative emotions, for example, can orient our attention system to incongruence and incoherence. Negative emotional responses, such as anger or sadness, signal and are related to the experience of specific unmet needs. The assumption here is that there is a basic need or drive for internal coherence for compelling negative emotional processes to be resolved. Thus, the urgency of negative emotions orients one to a concern and, when used productively, they organize to “deepen and differentiate” that experience so it might be addressed (Greenberg, 2019). In contrast, positive emotions are about the experience of having one’s needs met. Feeling good supports one to “broaden and build” on experience, whether that be of attachment, personal achievement, or connectedness (Fredrickson, 2001). Positive, negative, adaptive, and maladaptive emotional experiences inform us about the degree of internal coherence and the need to resolve inconsistencies. The integrating function that emotion plays in the brain is the neural substrate of this idea (Schore, 2019). Fourth, emotions are associated with a network of cognitive, affective, motivational, somatic, behavioral, and relational information that is encoded in memory. Emotional experience and responding are mediated by the activation of this associative network. These networks, or mental structures, are dynamic and continually elaborated by new experience. Thus, emotion combines with bodily experience, cognition, and these other elements to provide information about the idiosyncratic meaning of events, including one’s values

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and concerns. In this way, emotion can be understood as a highly complex meaning system that is able to integrate all relevant facets of one’s circumstances into an overall visceral experience. Thus, emotion provides information about the self and, at the same time, directs the self toward some implicit or explicit goal. The experience of emotion involves accessing a need and is an appraisal of that need (Frijda, 2016). Finally, emotions are an interpersonal communication system telling others to draw closer or back off. Experience and appropriate expression of emotion increase the likelihood of getting interpersonal needs met. In sum, experiences such as complex relational traumas, which disrupt the adaptive emotion orienting system, result in a host of impairments in adaptive functioning. Emotion Structures or Schemes Emotional memory consists of an associative network of physiological, affective, cognitive, motivational information. The term most frequently used to refer to this information network is the behavioral construct of an emotion structure (Foa et al., 2019). From this perspective, traumatic experiences are encoded in emotion structures centered on the experience of fear. Current stimuli that resemble the trauma can activate feelings of fear and helplessness, associated somatic experience, the desire to escape the danger and avoid harm, and beliefs about self and the situations formed at the time of the trauma. Exposure procedures are intended to activate this fear structure so that maladaptive components are available for modification. Activation takes place through attention to sensory and somatic aspects of the trauma memory. Emotion-focused theorists prefer the term emotion scheme (Greenberg, 2019) to refer to this complex system of information. The purpose of briefly introducing this concept here is to highlight how it informs the principles of working with emotion in clinical practice. Whereas the term structure conjures a static representation, the term scheme highlights the goal-directed behavior that is so integral to emotion. Thus, emotion schemes are at once representations of experience and, at the same time, plans of action or intentions. Consequently, from an emotion-focused therapy perspective, articulating an emotional experience implies a need or intention that organizes the client to carry out those intentions in the environment. EFTT therapists emphasize and explicitly help clients attend to and articulate this aspect of emotional experience and affective meaning, which helps to activate client goal-directed behavior. Another set of terms used to refer to these mental structures are derived from attachment theory—terms such as object relations (Fairbairn, 1952) or internal working models of self and others (Bowlby, 1988). These complex mental structures comprise feelings; images; memories of needs, met or unmet; and implicit or explicit beliefs and expectations about self and intimate others formed in attachment relationships. Again, the entire network of information contained within these structures can be activated in current situations and influence current perceptions and behavior. Although some attachment-based theories (e.g., Bowlby, 1988) emphasize the representational and conceptual

58  Emotion-Focused Therapy for Complex Trauma

aspect of the information network (i.e., perceptions, beliefs, expectations), it is universally recognized that these mental structures are formed in affectively charged experiences with attachment figures. EFTT theory and practice explicitly focus on emotion as the central aspect of these mental structures, and affective meaning concerning self and others is the target of intervention. EFTT also draws on a constructivist understanding of multiple selves and self-organizations whereby an individual has different cognitive–affective– behavioral aspects of self in their repertoire, and one aspect may be most prominent at any point or may be generally prominent over time and across situations. Even so, except in the most extreme cases, other less salient selforganizations are available for awareness and integration into emerging experience. Prominent self-organizations resulting from complex trauma typically center on feelings of vulnerability, worthlessness, inferiority, and incompetence. Change in EFTT results from activating and strengthening more adaptive aspects of self (e.g., the compassionate or resilient self) so these become more prominent over time. Overall, the terms emotion scheme, with its emphasis on intentions, and self-organization, with its potential for multiple selves, emphasize the target therapeutic intervention and capture this dynamic, rather than structural, nature of psychic organization (Pascual-Leone, 2009; Pascual-Leone, Yeryomenko, et al., 2016). All that said, and at the risk of glossing over subtle but important theoretical distinctions, we use the terms emotion scheme and emotion structure interchangeably, with the understanding that we emphasize emotion as a dynamic action plan rather than a static representation. We also understand the terms selforganization, internal representation, and object relations as descriptors that refer to the core affective meaning systems formed in affectively charged experiences with attachment figures and activated by current affective experience. Types of Emotions: What to Look For One of the hallmarks of the general model of emotion-focused therapy is a highly differentiated perspective of emotion. Greenberg and colleagues (Greenberg & Paivio, 1997; Greenberg et al., 1993) introduced the field to a taxonomy of different kinds of emotion and associated emotional-processing difficulties. This is not intended to describe facts about emotion but rather as a useful heuristic that can guide appropriate intervention. However, over the last decade, research on emotional processing and this taxonomy has stood up to empirical testing. Research on emotion in psychotherapy has verified that conceptualizing emotions within this framework is both measurable and related to critical aspects of treatment outcomes (e.g., Herrmann et al., 2016; Pascual-Leone, 2018). Using this in session, clinical judgment about which emotional process to focus on is determined by empathic attunement to the client’s momentby-moment experience as well as knowledge of an individual client, personality styles, and disorders. This taxonomy is the basis of emotion assessment and intervention in EFTT.

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Primary Emotion The first type of emotion is an immediate and direct response to the environment that is not reducible to or mediated by other cognitive–affective components. Seminal theory and research have indicated that primary emotion corresponds to the limited number of discrete basic affects, including anger, sadness, fear, shame, joy, and curiosity or interest, that emerge across cultural groups at predictable developmental stages (Eckman & Friesen, 1975). Thus, in emotion-focused theory, primary emotion represents the initial underlying reaction to a presenting circumstance. Depending on the circumstances, the intensity of that emotion (arousal level), and the tacit meaning it might engender based on an individual’s learning history, primary emotion can be either adaptive or maladaptive. For example, under normal circumstances, fear in the face of danger is a highly adaptive experience. However, a person’s history of physical or sexual abuse can lead to experiencing fear when shown love and affection or in response to benign disagreements. Thus, feelings can be both a source of difficulty for clients and a potentially guiding referent for self-development. Primary Adaptive Emotion Primary emotional responses that are adaptive function to mobilize healthy resources and action. Fear of imminent danger is an obvious example of a primary and adaptive emotion that mobilizes action to avoid a threat. However, over the course of psychotherapy, the most prototypic examples of primary adaptive emotion tend to be feelings such as anger at violation and sadness at loss. Anger at interpersonal violation, for example, mobilizes self-protective resources and action. At the same time, sadness at separation or loss mobilizes withdrawal or seeking contact and comfort to promote healing. Processing difficulties concerning primary adaptive emotion involve problems with modulating its intensity that result in either underregulation or overcontrol. In either case, the information associated with the experience is not readily available to guide adaptive action. Survivors of complex trauma may feel overwhelmed by what might be adaptive experiences of anger or sadness, and they may chronically avoid these feelings. Truncating and avoiding the expression of these feelings robs one of the adaptive organizations these emotions have to offer. The result often is a pervasive sense of victimization and powerlessness, self-blame, recurrent bouts of depression, and difficulties with assertiveness and establishing appropriate interpersonal boundaries. Primary emotional experiences, such as grief about loss or the shame of rejection, are frequently avoided because they are painful. This type of emotion is more complex than basic emotions but is nonetheless adaptive because it informs the individual that damage to the self has occurred. These painful emotions need to be allowed and fully experienced so that information can be integrated into current meaning and the sense of self. In general, appropriate intervention for primary adaptive emotions that are inhibited typically involves increasing their awareness, symbolization, and healthy expression.

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The purpose of this is to access emotion and the associated adaptive information and promote appropriate expression of the experience. Until recently, an area that has been less often discussed in the clinical literature is that of positive emotion. Emotions such as curiosity and joy are considered primary adaptive experiences that serve the function of expanding and building on healthy experiences (Fredrickson, 2001). Self-compassion, although not a discrete emotion, is considered a positive emotional experience that is important to therapeutic change (Gilbert, 2014). In addition to this, attachment, which is a fundamental process in human development, is driven by an affective system that (among other things) orients one to seek out positive, warm relationships that provide associated positive feelings. Complex relational trauma disrupts the individual’s capacity for positive affect and healthy attachments, and EFTT aims to restore these capacities. Primary Maladaptive Emotion Primary emotions that are maladaptive are also immediate and direct responses, yet they do not serve an adaptive function. In the process of psychotherapy, the most prototypic examples of primary maladaptive emotion are traumatic fear and shame, which frequently underpin other unhealthy and alienating experiences such as guilt or loneliness (Pascual-Leone, 2018). These also can be conditioned maladaptive responses. One obvious example is overgeneralized fear associated with posttraumatic stress reactions. Intervention in these cases involves counterconditioning of the maladaptive fear response (creating new associative links) and, at the same time, validating clients’ feelings and exploring sources of actual trauma or harm. In many cases of complex trauma, the person’s core sense of self is constructed around primary maladaptive emotions, particularly fear and shame, that result in crippling collapse or withdrawal and bodily correlates of chronic tension, shutting down, or hyperarousal. A holistic and pervasive experience of self as insecure or unacceptable is automatically activated in current situations. However, the experience of vulnerability or shame is not obviously caused or preceded by other underlying cognitive–affective processes. Selfcriticism, especially when delivered in a harsh affective tone, can be understood as resulting from the activation of a core sense of self as shamefully bad or broken and therefore deserving of criticism. Appropriate intervention requires processes that resemble those used in the counterconditioning of primary maladaptive fear. This involves accessing a core maladaptive sense of self (typically through memory evocation) with its constituent thoughts, feelings, and somatic and sensory experience and then simultaneously accessing more healthy resources (e.g., adaptive emotion) to create new associative links and thereby restructure the sense of self. Secondary Emotion Secondary emotions follow or result from more primary cognitive or emotional processes—a sequence of thoughts and/or feelings that is readily observable in the session. These forms of emotional experiences are longer lasting

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rather than immediate and fleeting responses to one’s presenting circumstances, as in the case of primary emotion. One difficulty occurs when emotion is a secondary reaction to maladaptive self-statements or thoughts. An example frequently observed in posttraumatic stress reactions is anxiety resulting from catastrophic expectations (e.g., the world is dangerous, others are hurtful). Irrational as these beliefs may be, their poignancy comes from a deeper sense that one is ultimately unable to cope or even survive, which implies a deeper primary maladaptive emotion about ones’ vulnerability. Another example of secondary emotion is shame resulting from self-critical statements (e.g., a client might say, “What an idiot I am! I should have known better”). Although self-criticism sometimes embodies deeper primary maladaptive processes, at other times, these harsh self-criticisms are better understood as learned injunctions or incorrect or inappropriate negative beliefs. The resultant secondary emotions need to be explored to promote awareness and change their maladaptive meaning. Self-critical clients need to become aware of both the content and harshness of their negative self-statements and the experiential impact of these statements. This experiential awareness can help activate a more self-affirming stance, often based on adaptive anger at harsh or unfair self-statements. In other instances, the emotion is secondary to and masks more core emotional experience. Trauma survivors can be afraid of or feel guilty about anger they may harbor toward a parent, or they sometimes respond angrily to their own more vulnerable feelings of fear or shame. Secondary or defensive emotions such as these should be bypassed to access the more core emotional experience and the information associated with it. For example, the client who routinely expresses anger at signs of interpersonal slight needs to gain access to underlying feelings of hurt or sadness. Similarly, the client who collapses in tears at memories of violation needs to access more powerful feelings of resentment and anger. Other complex secondary emotional responses include global distress and anxiety and depression. Global distress is an undifferentiated emotional response characterized by high arousal and low meaning that needs to be differentiated into its underlying constituents. When clients are feeling distressed, they might need help regulating, containing the experience, and finding the right words to express the more primary experience that underlies it. Sometimes global distress will differentiate into an adaptive emotion, such as sadness, while at other times, the root of distress will be clearly maladaptive (i.e., the same old feelings of shame). Depression and anxiety are frequently associated with posttraumatic stress reactions. Feelings of powerlessness, defeat, or emptiness associated with depression are complex “bad feelings” generated by cognitive–affective sequences or the activation of a core maladaptive sense of self, yet they are global and nonspecific. A depression, for example, could comprise unresolved sadness at the loss of a relationship, coupled with shame at having been rejected; a core sense of self as basically unlovable, which includes self-contempt for being

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“such a loser”; beliefs that one is doomed to be alone; and a collapse into powerlessness and despair. Here, as with other secondary emotions, the intervention strategy is to access the core sense of self and explore the underlying cognitive– affective and sensory components to arrive at more adaptive resources, such as suppressed anger at violation and sadness at loss. Instrumental Emotion The third broad category is instrumental emotion, which is used, consciously or unconsciously, to influence others. Classic examples include crying “crocodile tears” to elicit sympathy or attention or raising one’s voice in anger to overpower or control others. These types of expressions may or may not be accompanied by genuine emotion. However, instrumental emotions are not necessarily false; they can entail real affective experiences with genuine arousal, and in many instances, individuals may be unaware of the way they are using emotion. For example, a man with a history of angry outbursts when his demands are not met is likely to be having genuine experiences of anger and frustration. However, the fact that his outburst usually results in him getting his way provides repeated reinforcement for his angry behavior. These types of emotions need to be changed. Intervention involves confronting and interpreting the instrumental function of the emotion and teaching more adaptive ways of getting one’s needs met. Both secondary and instrumental emotion can be problematic at the level of intensity, and in these instances, intervention needs to include emotion regulation strategies. All emotion types can be problematic at the level of chronicity or frequency, such that anger, fear, or sadness is an overdominant emotion experienced or expressed. In these cases, individuals can have limited awareness of and access to other feelings, so intervention consists of implicit or explicit emotion coaching or awareness training. Table 3.1 summarizes the different kinds of emotion, their associated difficulties, and intervention principles. Intervention for each of these types of emotion is designed to activate specific change processes or types of emotional processing. These are the focus of the following section.

CHANGE PROCESSES: EMOTIONAL PROCESSING IN EFTT There is widespread agreement that avoidance of trauma feelings and memories can perpetuate disturbance and that clients need to confront these painful experiences to heal (Foa et al., 2019). Outside of the area of trauma, the notion that exploring bad feelings makes one feel better has been a widely held belief among several schools of psychotherapy (e.g., Freud, 1933/1961; Perls et al., 1951; Rogers, 1980). Nevertheless, leading clients to feel bad so they can feel good is counterintuitive and can be an obstacle for clients and clinicians alike. More recently, there has been wide interest in the puzzle of what exactly “emotion processing” is and how it occurs. Answers to this puzzle

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TABLE 3.1.  Types of Emotion, Associated Difficulties, and Intervention Principles Type of emotion Primary

Painful emotions Primary Core sense of self Secondary

Defensive Complex “bad feelings” Instrumental

All maladaptive

Difficulties Adaptive Dysregulation or overcontrol (e.g., fear of actual danger) Inappropriate expression Avoidance (e.g., anguish of loss) Maladaptive Overgeneralized response (e.g., fear in posttraumatic stress disorder) Activated across situations (e.g., self as worthless) Reactions to maladaptive cognitions (e.g., anxiety from catastrophic expectations) Masks more core emotion (e.g., anger covering shame) Activated across situations (e.g., powerlessness) Used to control others (e.g., anger or tears) Dysregulation Chronicity or frequency

Intervention principles Reduce or increase arousal Model or teach expression skills Allow and explore Validate, countercondition Access and restructure Explore and modify cognitions Bypass and access core emotion Attend to and explore Confront, access needs, teach better ways to get needs met Reduce arousal Increase access to other emotions

Note. Adapted from Working With Emotions in Psychotherapy (p. 37), by L. S. Greenberg and S. C. Paivio, 1997, Guilford Press. Copyright 1997 by Guilford Press. Adapted with permission.

are important when clinicians of virtually all theoretical orientations find themselves sitting across from a distressed client who is unable to surmount or push through intensely painful emotions. In general, emotional processing refers to the process of change whereby emotion structures or schemes are activated in therapy so that new information can be integrated into the scheme. The means of activation, targets of change, and sources of new information vary across approaches. In cognitive behavior therapy (CBT), for example, imaginal exposure procedures are used to activate the fear structure and constituent maladaptive associative links, reactions, and faulty attributions, such as self-blame. The sources of new information include new learning through habituation, challenging mal­ adaptive cognitions, and psychoeducation about trauma. In relational psycho­ dynamic approaches, traumatic experiences are more typically explored in the therapeutic relationship; maladaptive elements include defensive processes and interpersonal patterns, and the primary source of new information is therapist interpretations. The construct of emotional processing is the primary mechanism of change in exposure-based therapies (Foa et al., 2019) and has been incorporated more broadly into other approaches. For example, in CBT, there is increasing

64  Emotion-Focused Therapy for Complex Trauma

emphasis on the construct of hot cognitions, or emotionally charged thoughts (Safran & Greenberg, 1987), and the process of accessing thoughts when exploring affectively charged experiences. This is based on the recognition that maladaptive thoughts accessed in this way are more idiosyncratic and personally meaningful, relevant, and memorable. Recent theory has recognized the importance of exploring both affect and meaning construction and has integrated these into new cognitive models. Emotional processing in EFTT is understood more specifically and is a more multifaceted construct than is described in other psychotherapeutic approaches. As discussed in the preceding chapter, EFTT recognizes that trauma, particularly complex trauma, involves more complex emotions than just fear. Common exposure-based interventions are designed for reducing fear but have not been found to be effective in modifying other emotions such as sadness, anger, guilt, or shame. Trauma and childhood abuse adversely affect individuals such that they experience their world in restricted and maladaptive ways. Thus, the aim of EFTT is to increase the range, depth, and meaning associated with clients’ feelings. An emotion-focused approach helps promote emotional competence through several processes that are subsumed under the broader term emotional processing. These subprocesses and the specific emotions they target are the topics covered in the remainder of this chapter. How to best work with a presenting emotion depends principally on the nature of a client’s presenting concerns and the short- and long-term goals of the treatment. Therefore, an essential task in working with emotion is assessing what kind of processing is most useful when the client expresses a specific emotion. Most therapists will have had an experience in which a client pre­ sents several emotions that emerge in rapid succession. For instance, a client complains bitterly about the constant criticism by her mother; expresses contempt for her mother’s self-centeredness and immaturity; collapses into tears and weeps, “It’s hopeless, she will never change”; then shifts to feeling conflicted about wanting to cut the mother out of her life but needing the mother’s support; and worries about her own security. All these are important issues and processes. Therapists might find themselves asking what to focus on. Which emotion is most important? How do I figure out what the client needs to do to continue processing emotion? Emotion-focused therapy theorists (Greenberg & Goldman, 2019b; Greenberg & Pascual-Leone, 2006) have identified major ways of productively working with emotion, all of which describe different subtypes of emotional change processes that are relevant to trauma therapy and EFTT. These different change processes include (a) emotional awareness and arousal; (b) downregulation of emotional intensity; (c) reflection on emotion; and (d) emotional transformation, in which a maladaptive emotion is transformed by the emergence of another adaptive emotion. For example, shame and self-blame for having been abused can be transformed by anger and holding a perpetrator responsible for harm or sadness and compassion for one’s suffering.

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Awareness and Arousal Insight-oriented therapies are founded on the assumption that increasing client awareness of emotional experience—usually the origins, meaning, and consequences of maladaptive emotion—is an important change process. Awareness of emotion and emotional arousal are distinct processes that are relevant to trauma. For example, alexithymic clients can experience high levels of distress (arousal) but have no awareness of specific emotions; other clients can clearly identify their specific emotions (e.g., anger) but are numb or flat. The change process is different for these different individuals. Nonetheless, emotion-focused therapy theorists have discussed these together because increasing awareness often requires a certain degree of arousal and immersion into bad feelings and emotional pain. Again, this is fundamental to the effectiveness of exposure-based procedures. This also is the assumption underlying posited change processes of emotional insight and challenging hot cognitions. This is especially relevant to clients with histories of complex trauma who are cut off from and have limited access to internal experience. They cannot move through the change process until they at least have some access to emotional distress that can be further differentiated. EFTT therapists should facilitate client arousal and awareness from the beginning of therapy. Clinicians need to be selective about which experience to attend to for promoting further processing. Any time clients present and elaborate on their experience of trauma, there are several possible facets of that experience on which a therapist might choose to focus. However, not all facets of that experience have equal potential for client progress. When emotions are suppressed or avoided, such that clients feel flat or numb, deliberately increasing arousal is productive. This is not for cathartic purposes but rather to activate the emotion structure and thereby increase awareness of the information associated with emotional experience. Although arousal of emotion is clearly important, simply purging or venting emotion is not a productive process. Rather, it is the deep experiencing of emotion that includes some articulation of its meaning (e.g., causes, unmet needs, the effects on self and relationships) plus expressed arousal that is most indicative of progress (Greenberg, 2002). In short, arousal plays a critical role in ushering in and vivifying awareness. When a client approaches emotions that are not defensive or secondary reactions, it is productive to increase emotional awareness. Feelings of assertive anger, grief, or nonblaming expressions of hurt are all primary and adaptive emotions that are meaning laden and, to a useful end, can be explored and experienced more deeply. True to an experiential approach, the primary intervention for doing this in EFTT is empathic exploration. Empathic responses are used alone or in conjunction with other procedures, as was presented in the preceding chapter. The EFTT therapist will deliberately guide the client’s attention and awareness, particularly toward newly and spontaneously emerging facets of emotion.

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This process is exemplified by a client who had become estranged from her family and most recently had a falling out with her sister: CLIENT:

I’m so fed up with her behavior. I’d be very happy not to have to see her again, ever!

THERAPIST:

What happens inside you when you say that?

CLIENT:

[sighs] Oh, I don’t know, just a feeling of sadness.

THERAPIST:

Sadness.

CLIENT:

Yes. Because I remember happy times, summers at the cottage, our kids playing together. The thought of never having that again . . .

THERAPIST:

So, it’s like sadness at losing her?

CLIENT:

[tears well up in her eyes] Yes, very sad at losing her, her more than anyone.

Increasing awareness and arousal is also an important change process in working with primary maladaptive emotions that are central to the client’s sense of self. Clients exert great efforts to get rid of and ignore feelings of vulnerability and worthlessness, and therapists may be reluctant to approach and intensify these experiences. Nonetheless, these experiences need to be activated in session to increase client awareness of the associated information. This can be accomplished by evoking and exploring memories of situations (traumatic events) in which the core sense of self is developed or by exploring current situations in which it is activated. For example, one client was recounting for the first time the experience of being raped by her father when she was a child. These memories had always been highly distressing, and the only part she had been able to recall of her experience was fear and the pain, which she would quickly shut out of her mind. The therapist validated this and queried for more. THERAPIST:

Yes, it must have been so painful. Can you get past that? Was there anything else going on in your little mind as a child?

CLIENT:

[thoughtful] I remember him saying, “Daddies do this to their little girls.”

THERAPIST:

Stay with that. What did you think when he said that?

CLIENT:

At the time, I was so confused. I remember thinking I must have done something wrong, that my mother would be angry at me. But I couldn’t figure out what I had done.

THERAPIST:

So, somehow you were at fault, a bad girl?

Here, by increasing arousal and activating trauma memories, the client clearly accesses information that was not previously available—that is, core maladaptive shame and associated maladaptive beliefs about self that were

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formed at the time. These now are available for exploration and change. How shame can be transformed is another change process that we discuss next. Downregulation of Emotion The previous example of exploring trauma memories illustrates that there is a delicate balance between facilitating emotional arousal in the service of awareness and managing intense emotion. Generally, it is most productive when clients can take a reflective stance regarding their emotions, allowing the feelings to be active yet sufficiently regulated to be useful in the exploration and creation of new meaning. Emotion regulation and associated self-soothing are essential processes in all trauma therapies. In current CBT and eye movement desensitization and reprocessing (Shapiro, 2018) approaches for complex trauma (e.g., Jackson et  al., 2020), emotion regulation strategies are taught in the early phase of therapy before trauma exploration. In current experiential approaches, emotion regulation is part of the overall fabric of therapy and is accomplished largely by providing a safe and empathic therapeutic relationship. This relationship provides a suitable context for processing painful traumatic experiences. Therapists should be mindful of clients’ capacity for emotion regulation in the early phase of EFTT when painful emotions are disclosed for the first time. Later, in the middle phase, clients will frequently need to be coached through self-soothing and regulation strategies to both tolerate and work through painful emotions. Facilitating the downregulation of emotion is important when clients are overwhelmed by distress, secondary emotions such as rage, or primary maladaptive emotions such as shame or fear, as in panic attacks (see the top of Figure 3.1). The short-term goal of emotion regulation is to gain psychological distance from these experiences to help clients turn down the intensity. Intervention in these instances involves the empathic affirmation of client vulnerability, followed by helping the client articulate the meaning of emotional pain. The long-term goal of this empathic regulation of affect is to help clients develop their capacity to calm and comfort themselves by internalizing the soothing responses of the therapist and constructing meaning that makes distressing experiences more comprehensible and manageable. For example, a client in the middle phase of EFTT who had suffered physical and emotional abuse as a child described his feelings of shame in social settings. Although the client became highly distressed, his therapist joined him in empathically exploring the meaning entailed in this painful emotion. CLIENT:

Umm. Everything I say is just a bit off, you know. . . . Off of how other people see or . . . talk about things. [His voice cracks, and he sobs heavily.]

THERAPIST:

It’s just really . . . it hurts to say that. . . . Can you say what hurts so much?

CLIENT:

[He sniffles. There is a long pause.]

PHASE 1 Emotion task: approach emotion, explore and differentiate (secondary) distress

Degree of Emotional Processing

Low

Global distress

PHASE 2

Shame, fear, or loneliness

Rejecting anger

Emotion task: work through maladaptive emotion

Express self-contempt

Clinical task: self-related difficulties (e.g., self-critical process related to shame, loneliness, depression, self-doubt, anxiety)

Negative evaluation

Need Feel relief

Clinical task: relationship building, modulate arousal, focusing on emotion

Behavioral self-soothing

Positive self-evaluation Assertive anger or self-compassion Positive

PHASE 3 Grief, hurt

Feel relief self-evaluation

High

Acceptance and agency A sense of closure, resolution Approach

Action tendency

Emotion task: facilitating primary adaptive emotions Clinical task: interpersonally related difficulties (e.g., complex trauma, unfinished business, attachment issues)

Withdraw

Adapted from “Emotional Processing in Experiential Therapy: Why ‘the Only Way Out Is Through,’” by A. Pascual-Leone and L. S. Greenberg, 2007, Journal of Consulting and Clinical Psychology, 75(6), p. 887 (https://doi.org/10.1037/0022-006X.75.6.875). Copyright 2007 by the American Psychological Association.

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FIGURE 3.1.  The Sequential Model of Emotional Processing

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THERAPIST:

It’s just a feeling of inadequacy that gets pulled . . . or . . .?

CLIENT:

Well, yeah, I need to monitor everything I say, even while I’m saying it because I’m . . . I know or feel that everything I say is just a little bit off—just doesn’t. . . . You know, people will just do a double take or disregard me as a nutcase.

In this example, instead of deflecting emotion or breaking down into despair, the client begins to follow the therapist’s attentive and empathic initiative and begins to articulate the meaning of his feelings. In so doing, the dyadic process serves to regulate his arousal into a productive range. Reflection on Emotion The process of reflecting on emotion results in increased self-awareness. Research has shown across several contexts that being able to symbolize and explain traumatic emotional memories promotes their assimilation into a coherent personal narrative, which, in turn, promotes healing (Paivio & Angus, 2017; Pennebaker & Chung, 2011). In the context of traumatic events, individuals sometimes make appraisals about themselves, others, or the nature of events that are later shown to be untenable. For example, a woman who recalled how her parents “helped” her with homework during grade school described her emotionally volatile mother leaning over, screaming at her as she struggled with homework and the periodic beatings by her father that followed any wrong answer. As an adult in treatment, she remembered weeping as a child, feeling exhausted, and thinking how she was obviously unintelligent and unable. However, after reflecting on the terror she felt, she eventually concluded that any child would have had difficulty performing under those conditions. From a cognitive perspective, reflecting on emotion can be understood as a way of changing a client’s assumptive framework (Beck, 2021). From an emotionfocused therapy perspective, productive reflection on meaning is always “hot” or grounded in presently felt emotional experience. All types of emotion are suitable targets for reflection; this will also be an important process in all phases of EFTT. Reflecting on secondary emotions, such as anger at feeling ashamed, can help clients become aware of the reactive nature of some of their feelings. Similarly, considering the present and historical context of meaning related to primary adaptive emotions will help clients understand their needs and take appropriate action. Anger at interpersonal boundary violations, for example, can help the client focus on setting boundaries rather than letting anger become too diffuse when it is aroused in the moment. Finally, it also can be useful to reflect on primary maladaptive emotions and consider them from a certain psychological distance, at which point they are not as difficult to manage or endure. This can allow clients to take a bird’s eye view of themes or patterns in their life. Insight is a classic form of reflection on emotion. A traditional psychodynamic intervention is to communicate an interpretation in the hopes of facilitating insight. An interpretation is usually based on the therapist’s appraisal of

70  Emotion-Focused Therapy for Complex Trauma

core themes relevant to the client (e.g., “This seems a lot like the kind of power­ lessness and depression you used to experience with your father; rather than experiencing your rage, you collapse”). Therapists in EFTT might guide the client exploration process but do not presume to be experts in the client’s experience or dynamics. Following this intervention principle, therapists encourage the client to articulate insights as they emerge from the client’s perspective. Finally, reflection on emotion also is facilitated by modeling a discoveryoriented approach in which therapist and client alike are trying to understand the client’s story of emotion (e.g., “Somehow you collapse into feeling like that powerless little boy. How does that happen? What goes on for you on the inside?”). Promoting the exploration of emotional meaning and constructing new meaning from this process is the primary source of new information or insight in EFTT and the focus of the following chapter. Emotional Transformation In the effort to facilitate emotional change, therapists must help clients first to access primary adaptive emotion so the associated adaptive information is available. Moreover, primary maladaptive emotions must also be accessed, explored, and specified, albeit for a different reason. Only when the core concern of emotional suffering—primary maladaptive fear or shame—is differentiated can one reorganize the wounded or maladaptive facet of experience. Thus, although emotional experiences that emerge in the early and middle phases of EFTT (global distress, fear, shame, cold or destructive anger) may not be curative in and of themselves, unpacking and exploring such emotions will yield both clarity about concerns and an opportunity to reorganize toward healthy, more productive ways of being. One of the principles in EFTT, then, is to empathically respond to distressing, even maladaptive emotions while continually supporting the tentative emergence of adaptive emotional responses. In this way, bad feeling is not purged or vented as such, nor does it attenuate, but rather another feeling is evoked in parallel and in contrast to the maladaptive feeling (Pascual-Leone & Greenberg, 2007). Although adaptive emotions, such as anger and sadness, are not necessarily enjoyable, this transformation of emotion is due in part to the fact that they are incompatible with maladaptive emotions such as fear and shame. The initial targets of emotional transformation and intervention in the middle phase of EFTT (see Figure 3.1) are primary maladaptive fear and shame—complex and dysfunctional affective-meaning states that tacitly embody a core sense of self as incompetent, bad, and unlovable. These are embodied preverbal experiences that are not easily amenable to logical or rational change. For example, the client who had been raped by her father stated, “I know that he was the adult, and I was just a child, but I still feel like I was responsible.” Another client said, “I know in my mind that I am successful— I have a PhD, for God’s sake! But I still always have this sense that there’s been some misunderstanding or error.” The fact that these feelings defy rational thinking makes it difficult to change maladaptive emotions directly.

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In short, primary maladaptive emotion is transformed by accessing and evoking primary adaptive emotion. This process typically occurs toward the end of the middle phase and throughout the late phase of EFTT. Although this transformation process cannot be applied formulaically, there seem to be some prototypic pathways that are supported by process research (Pascual-Leone & Greenberg, 2007). Maladaptive fear, for example, about being preyed on by potentially abusive others, can be transformed by supporting the simultaneous emergence of assertive anger in which the client actively defends her boundaries and dignity. Similarly, shame that involves feeling damaged and unlovable can be transformed by simultaneously accessing sorrow and compassion toward oneself. Shame and maladaptive self-blame associated with trauma can also be transformed by accessing justifiable anger at the actual perpetrators of harm. Therapist interventions that facilitate emotional transformations in EFTT have been studied in detail (e.g., Paivio et al., 2001). For example, in unresolved feelings toward others, imaginal confrontation of perpetrators of harm is a principal way of facilitating emotional transformations. In the context of selfrelated difficulties, two-chair enactments between adaptive and maladaptive parts of the self are useful. During these enactments, therapists guide the client’s attention to facets of their experience that may only be on the periphery of awareness. In the following excerpt from therapy, a woman diagnosed with depression describes her relationship with her father, who emotionally abandoned her as a child after her mother died. The client begins in a state of maladaptive shame, feeling as though there was something about her that deserved to be rejected. As she explores this feeling, there is a sense of anger. After noticing this, the therapist guides the client’s attention toward those aspects of the unfolding experience, transforming her sense of worthlessness into a more powerful self-assertion. CLIENT:

He was never there for me. All the suffering I put myself through—I guess I have only myself to blame.

THERAPIST:

I hear this sense of somehow not deserving love. . . .

CLIENT:

[Tears fill her eyes.] I feel I’ve had too many losses in my life. It seems so unfair. I had to deal with so much on my own. I hate him for what he did.

THERAPIST:

Tell him what he did [points to empty chair].

CLIENT:

I don’t think you realize. . . . All my relationships, everything, has been so much harder . . . because of the way you treated me. Every single day I’ve had to fight through that. . . .

THERAPIST:

What do you resent? Tell him. . . .

CLIENT:

I resent that you didn’t love me. I hate you for being so selfish, inconsiderate, and dismissive of me and . . . and . . . [long pause] . . . for just never putting me first. [pause] Not that I needed that always. . . .

72  Emotion-Focused Therapy for Complex Trauma

THERAPIST:

What just happened there . . . something changed?

CLIENT:

I’m feeling sorry for myself.

THERAPIST: Okay. Try not to go there, stay with your resentment for

now. . . . I know it’s difficult, but tell him more about your resentment. CLIENT:

It’s hard for me to confront you, but this I must say: You were not a decent father to me. You abandoned and neglected me . . . for most of my childhood . . . and I’m angry at you for that.

In this example, maladaptive shame undergoes a microtransformation as subdominant feelings of anger and healthy entitlement are brought to the foreground. Through this process, the client eventually expresses adaptive assertive anger, which is supported by the therapist over the course of therapy until it becomes a new, healthy part of the client’s repertoire.

MODEL OF CHANGE AND PHASES OF EFTT The following sections present a model of sequential emotional change processes that guide the process of EFTT. Research Supporting an Integrative Model of Change Recent quantitative and qualitative research has helped articulate different types of emotion and change processes that are central to the phases of EFTT. Figure 3.1 shows key findings from this research (Pascual-Leone, 2018). These findings are based on 25 process-outcome studies of diverse approaches to therapy (e.g., emotion-focused, dialectical behavioral, short-term dynamic, attachment-based family, psychiatric management) for diverse presenting problems (depression, anxiety, adjustment disorder, personality disorders, especially borderline personality disorder), including the study in which the client Monica was a participant. All these presenting problems included in analyses are comorbid with complex trauma and therefore relevant to EFTT. Empirical support for the model presented in Figure 3.1 indicates that when emotion events during a session result in productive outcomes, key phases of emotion are likely to emerge in a sequential pattern (Pascual-Leone, 2018). The generalizability of this model underscores the degree to which therapists can integrate the EFTT treatment approach presented in this book with the therapy they may already be most familiar with. Regarding practice, identifying the subtypes of emotion identified in the model is important for therapists because these will be the targets of specific emotional-processing inter­ventions. Moreover, the model of emotional processing corresponds to the model of resolution that is the basis of EFTT (see Chapter 6) and can be used to illustrate different phases in the EFTT treatment model.

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Moving Through the Model: A Dynamic Process Although the model of change presented in Figure  3.1 begins with global distress, it is important to remember that for many clients who have suffered complex trauma, there may not be any overt signs of distress at the beginning. So, while some clients will be easily triggered and overwhelmed by their feelings of secondary (symptomatic) emotion, others will present as relatively detached and avoidant of their feelings. For clients who are avoidant, the first objective in EFTT is to foster emotional engagement, which is the entry point to awareness. Chapters 6 through 8 offer specific strategies for doing this. Once clients begin to engage with their underlying emotional experience, the next objective is to differentiate those painful feelings while at the same time maintaining a tolerable range of arousal. At the starting point of this model in Figure 3.1 (i.e., global distress), the client is already emotionally engaged. From then on, the path toward emotional processing is nonlinear and reveals that there is more than one way clients process emotion. Although phases of EFTT are associated with certain target emotions and certain subtypes of emotional processing, the experiential process is typically cyclical and reiterative, in which clients oscillate between emotional progress and collapse. As a result, all the emotional processing subtypes we have discussed will be useful at different moments throughout treatment, depending on the client. Nonetheless, different phases of treatment do lend themselves to different emphases in emotional processing. According to this model (Figure 3.1), clients must initially work through specific reactive feelings that are undifferentiated and insufficiently processed. In the early phase of EFTT, clients identify target complaints related to traumatic experiences and, in so doing, begin to approach specific emotional content. Secondary and global feelings of distress are engaged and differentiated into more primary underlying feelings that are the core issues (see the top of Figure  3.1). The two types of emotional processing that are most useful in accomplishing this are emotional regulation to activate and manage intensity, on the one hand, and emotional awareness, on the other. One way of illustrating emotional change is to consider the emotions expressed when clients talk about the trauma they have suffered. A recent study examined the narratives told by men and women in EFTT, comparing narratives taken from early and late sessions (Khayyat-Abuaita et al., 2019). The first finding was that client expression of key emotional experiences (i.e., assertive anger, grief, self-compassion presented at the bottom of Figure 3.1) predicted good treatment outcomes in 80% of the cases, while absence or low levels of those emotions predicted poor outcomes in 70% of the cases. The second finding was that emotion dynamically shifts over phases of treatment, which is readily observable by therapists working in session. At the beginning of treatment, clients’ narratives about their trauma consisted mostly of global distress. However, by the later phase, these same narratives had come to include expressions of assertive anger, self-compassion, grief, and feelings of acceptance and agency. This showed that clients develop a richer and more adaptive

74  Emotion-Focused Therapy for Complex Trauma

emotional experience in relation to their trauma. By the time they told their final narratives, clients also showed greater expression of existential needs (e.g., safety, respect, love, mastery). Last, the Khayyat-Abuaita et al. (2019) study indicated that emotions emerge in a predictable order when the process is on track. In short, all this research suggests that Figure 3.1 offers a “process map” for working through emotional distress that is especially relevant to the treatment of complex trauma. It is important to note that, while emotional change of this kind is always dynamic and nonlinear, moving “two steps forward, one step back,” there are also distinctly different observable patterns over the long term for different clients. Some clients rehearse the same kind of emotional development (e.g., sequence) in repeated sessions, each time applying the change process to new content areas. This is one way that resolving one core trauma comes to subsequently generalize across various other experiences of abuse. Other clients will slowly work through a central trauma, methodically starting each session from a better place than the last (Pascual-Leone & Kramer, 2019). These patterns have implications for case formulation and treatment planning. Therapy with the client Monica can be used to illustrate the dynamic process of emotional change over time. She had been unable to make sense of and get over the suicide of her mother and was tormented by painful feelings and memories. She entered therapy in a highly distressed state that included both secondary and primary adaptive anger at her deceased mother. At the end of the early phase, confronting her imagined mother evoked gruesome memories of her death and in-session reactions of panic and anxious fear (see Figure 3.1). Emotional processing was accomplished by helping Monica manage distress while confronting these painful memories and simultaneously exploring and unpacking her feelings so she could begin to make sense of them. The middle phase of EFTT addresses self-related difficulties in which clients are grappling with feelings of primary maladaptive fear, shame, and sometimes rageful, rejecting anger (middle of Figure 3.1). Variations of fear and shame of this kind are typified by the overgeneralized fear response to threat in posttraumatic stress disorder or the sense of being defective and “bad.” Clients can also enter a state of rejecting anger (which is usually, but not always, a secondary emotion) for which the action tendency is to push the other away or wish to destroy them (e.g., “I don’t give a f**k . . . about him; he is dead to me”). Symbolizing the meaning of these feelings, including unmet needs, is critical to working through this second phase of treatment (middle of Figure 3.1). At a deeper level of processing, articulating a core negative self-evaluation (e.g., I am a loser) activates a contrasting existential need (e.g., to feel worthwhile), and this serves as a pivotal step in change, occasionally producing an experience of relief for the client. Activating adaptive feelings and needs facilitates change (emotional transformation) by developing new positive evaluations and experiences of self. In the case of Monica, all her life she had felt deep shame about her mother’s suicide and hid this from the world. Her worst fear was that her mother had not loved her—why else would she abandon her and cause her so much pain?

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A pivotal change moment in therapy came when she expressed this fear and need to feel loved to her imagined mother during an imaginal confrontation. She imagined that her mother, if she could, would respond with reassurance, nurturing, and love, and she felt comforted by this. These sequences are followed by primary adaptive emotions (bottom of Figure 3.1). On the one hand, clients can enter a state of hurt or grief, in which they acknowledge how they have been wounded and personal losses without complaint or self-pity. On the other hand, clients will become mobilized through assertive anger, in which they affirm healthy entitlement to fair treatment, worth, and/or connection with others. Similarly, clients can enter a state of compassion for self as a way of attending to their existential needs. Clients can shift between these states as they come to terms with themselves. The late phase of EFTT, in which the focus shifts to resolving past inter­ personal issues, is characterized by the full emergence of primary adaptive emotions. Therapists help clients deepen their experience of assertive anger in which offenders are held accountable for harm and primary adaptive grief for the losses they have endured (bottom of Figure 3.1). As they accept the reality of their trauma history, clients can access and develop adaptive resources of self-soothing and self-nurturing in the face of primary and nonblaming emotional pain. As in the second phase, clients eventually let go, forgive, or move on from these interpersonal issues through another emotional transformation. The middle and late phases of EFTT (self-related and other-related difficulties) also make special use of reflection on emotional meaning as clients process their feelings and construct new personal narratives about the self and other. A synthesis of adaptive emotions thus leads to a resolved state of acceptance, letting go of the past, and gaining personal agency. In the late phase of therapy, Monica moved back and forth between anger and grief over her mother’s suicide. Over time, she was able to assertively express and feel entitled to her anger at the damage and destruction caused by her mother’s actions. This helped to strengthen her sense of self. She also was able to fully acknowledge and grieve the enormity of the many losses she had endured. She was able to feel compassion for herself and view herself not so much from a position of deficiency but as a strong survivor. Monica now imagined her mother as more vulnerable and remorseful (“If she could undo the past, she would”) and remembered her mother as having been nurturing and loving to her when she was a child. She was able to forgive her mother and let go. At therapy termination, clients such as Monica continue to process emotion as they revisit the difficulties and issues explored in the treatment. This is a kind of recapitulation or review of experiences explored earlier in therapy. Processing therapy termination is most productive when it highlights experiences in the therapeutic relationship and the meaning of emotional experiences (“experiencing”) that were the focus of therapy. Cultivating a safe and collaborative relationship and promoting client “experiencing” are the fundamentals of EFTT and the focus of the following two chapters.

II PRAC TICE

4 Cultivating the Alliance

T

he primary task in Phase 1 of emotion-focused therapy for trauma (EFTT) is to cultivate a safe and collaborative therapeutic relationship. This is the exclusive focus of the first three sessions of therapy. The therapeutic relationship or alliance has long been identified as a universal change factor across treatment approaches and client groups (Horvath & Symonds, 1991) and is considered the foundation of therapy with survivors of child abuse trauma (Ford & Courtois, 2020). A compassionate, empathic, and collaborative therapeutic relationship has two primary functions. First, it provides clients with a safe environment for reliving painful feelings and memories. Second, this relationship quality can be a new interpersonal experience that helps to correct the effects of early attachment injuries and empathic failures. In this chapter, we define alliance quality, describe the fundamental intervention principles for cultivating a strong alliance, discuss the goals of alliance development in Phase 1 of EFTT, and provide specific guidelines for conducting the first three sessions. The chapter concludes with a section on addressing alliance difficulties and therapist errors that most frequently can occur during this phase of therapy. EFTT defines alliance quality in terms of both bond and collaborative elements. We use the short version of the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989; see Appendix B, this volume) both in our research and as a guide for clinicians to cultivate a strong and productive alliance. The attachment bond refers to affective aspects of the relationship: mutual liking and trust. Collaborative elements refer to

https://doi.org/10.1037/0000336-005 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  79

80  Emotion-Focused Therapy for Complex Trauma

agreements on the goals of therapy and the in-session processes or procedures that will be used to accomplish these goals. In EFTT, relationship tasks always take precedence over other tasks, regardless of the phase of therapy. Unlike psychodynamic approaches, in which the relationship and transference issues are the focus of therapy, in EFTT, transference issues become the focus of therapy only when they interfere with other therapeutic processes— in instances of client distrust, hostility, or boundary violations in the therapeutic relationship. This typically happens when clients have a long history of difficulties with interpersonal functioning and then also have similar troubles developing a good working alliance with their therapist. This is a marker for introducing a new conversation about the relationship itself, and transferencebased reflections are one way of doing that. However, unless it is an obstacle to productive collaboration, working through issues with the therapist is deemphasized in favor of resolving issues with abusive and neglectful others or attachment figures.

INTERVENTION PRINCIPLES FOR DEVELOPING A PRODUCTIVE ALLIANCE The intervention principles or therapist intentions that are most relevant to the initial phase of therapy with trauma survivors are elaborated in the following subsections. Communicate Compassion Compassion has become an increasingly important construct across therapeutic approaches and in popular culture. In general, compassion refers to the qualities of loving-kindness, tenderheartedness, and sorrow toward human suffering and pain (Gilbert, 2014). This is distinct from empathy (presented later), which involves understanding the meaning of specific experiences. Compassion is communicated nonverbally and through statements such as “I see how much you have struggled over the years. No child should have to go through this. I am so sorry you had to go through all that.” It also is commonly accepted that compassion also involves a commitment to help. This provides a human connection and models an attitude toward client suffering and pain that they internalize. Communicating compassion is, therefore, an essential ingredient in promoting change. Empathize Empathic responding is the primary intervention used throughout therapy to realize all principles or intentions and is particularly important in developing the therapeutic relationship in the early phase. As discussed in Chapter 2, the two main functions of therapist empathy with traumatized individuals are

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(a) modulating emotional intensity and (b) increasing client awareness and understanding of their emotional experience and processes (Paivio & Laurent, 2001). These processes contribute to client self-development and emotional control, and strengthening these client capacities, in turn, strengthens the therapeutic relationship. To review briefly, in terms of emotion modulation, empathic responses by therapists can reduce distress and isolation by communicating understanding, acceptance, and support (e.g., “I know how difficult it must be to get in touch with how profoundly victimized you were”). These empathic responses also can reduce anxiety about being judged and thus foster interpersonal trust. Empathic responses that affirm client vulnerability help them to allow and disclose painful and threatening experiences. In contrast, evocative empathic responses by therapists (e.g., “Yes, how painful—treated like you were some kind of vermin!”) can be used to deliberately increase emotional intensity and activate emotional experience and memories, making them available for exploration. Sharing emotional experience with a responsive therapist and collaborative exploration of that experience strengthen the bond. In terms of increasing emotional awareness, a therapist’s simple empathic responses (e.g., “You must have felt so resentful”) can direct clients’ attention to and help them accurately label emotional experience. These responses, when tentatively phrased, can be particularly helpful for clients who do not know what they are feeling and who fear negative evaluation. Empathic responses also help clients articulate and communicate the meaning of their emotional experience; this not only increases understanding but also fosters interpersonal connectedness. At other times, therapist empathic responses highlight the gist, central concern, or most poignant aspect of what the client said (e.g., “So, what hurts so much is this feeling of being completely invisible”). Still other statements invite elaboration or conjecture about client experience based on knowledge of the client and human experience in general. For example, in response to a client’s description of collapsing into powerlessness and depression, the therapist stated, “I guess you end up feeling like that powerless little girl all over again.” These kinds of responses strengthen the therapeutic bond and agreement on the value of emotional exploration as a therapeutic task. Validate Client Experience Validating responses is also important in reducing client anxiety, promoting client self-development, and fostering interpersonal trust in the early phase of therapy. Validation is distinct from empathy but requires empathic understanding. Whereas empathic responses communicate understanding or promote exploration, validation is a type of reassurance or a confirmation of reality in context. Validation of client experience is offered in response to client expressed or implied insecurity about whether their experiences or perceptions of a particular situation are accurate, legitimate, or normal (e.g., the

82  Emotion-Focused Therapy for Complex Trauma

client may say, “I’m probably weird” or “I don’t know why I think that. It’s probably nothing”). Validating responses (e.g., “It’s no wonder,” “That makes complete sense,” “That’s a part of having posttraumatic stress disorder”) reduce anxiety and fear of negative evaluation by normalizing clients’ feelings and perceptions and help them trust their experience. Linehan’s (1993, 1997) groundbreaking work focused extensively on the curative role of validation in therapy for borderline personality disorder, which is strongly associated with a history of child abuse trauma. Her model of dysfunction posits invalidating environments and client vulnerability as the primary factors contributing to borderline processes. Many individuals were repeatedly told they were stupid, crazy, or exaggerating and thus have internalized these messages and learned to distrust their feelings and perceptions. Therapist validation helps correct the effects of this early learning so that clients are better able to trust their internal experience as a source of information that can guide decision making and adaptive functioning. It is important to notice that validation is not the same as simple agreement with client opinions and perceptions or approval of their behavior. It is possible for therapists to communicate, for example, that substance abuse and self-cutting are understandable attempts to escape from overwhelming pain and, at the same time, emphasize the importance of learning less destructive ways of coping. Similarly, it is possible to validate clients’ need for strict emotional control and, simultaneously, challenge this need as excessive and not in their best interests. Provide Information Relationship development goes beyond empathic understanding. At the beginning of therapy, it is particularly important to provide information about trauma and the process of recovery, therapist and client roles, and clear expectations about the processes of therapy in EFTT. This information, combined with the provision of structure, helps reduce client uncertainty about treatment. Responding with an appropriate level of information when clients feel confused or distressed or are misinformed is itself an expression of empathic attunement. The following concrete information should be communicated to clients, with appropriate timing and according to their needs. Traumatic events are so horrible people desperately want to forget them, but, by definition, they are unforgettable. The more clients try to forget, the more these memories force themselves into awareness. Perseverating on traumatic experiences is a way of trying to make sense of and integrate the trauma into existing meaning systems. Clients need to remember and repeatedly tell the story in a safe environment to work it through. Clients need to process all the details with another person who can provide guidance, feedback, and support. When clients can come to terms with traumatic experiences without professional help, these resources generally have been available to them through family or friends.

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When trauma feelings and memories are chronically avoided, clients become stuck in the feelings and perceptions formed at the time of the trauma. If that happens, a part of the client usually remains fearful, powerless, angry, or ashamed, and this part gets activated at current reminders of the trauma. Powerful emotions are at the core of trauma—both the recurring bad feelings that clients want to change and healthy feelings such as sadness and anger that usually were suppressed because there was no support for their expression or they were punished. These feelings need to be expressed and understood. A therapeutic focus on past trauma is hard work, takes courage, and could temporarily activate symptoms and increase distress. Clients should be reminded that therapy will incorporate strategies to keep this manageable and will balance a focus on the past with attention to present concerns. Clients also need to be assured that they will have control over the process and pacing of trauma exploration. Together, the therapist and client will monitor the client’s level of distress and tolerance for trauma exploration and adjust the process accordingly. Define Therapist and Client Roles On the one hand, the client is the expert on their own experience. Their role is to share their experience (thoughts and feelings) with the therapist, including any concerns and difficulties with the actual process of disclosure and setting their own limits. On the other hand, the therapist is an expert on trauma and observing and responding to client in-session processes (“holding up a mirror”). In other words, therapists are experts in effective procedures, even though interventions are cued and guided entirely by client processes. This complementary relationship with respect to tasks is the essence of a marker-based approach and a hallmark of all emotion-focused therapies (as discussed in Chapter 2). At the same time, however, the therapist’s job is to encourage clients to push their limits and provide clients with the necessary guidance and support to make this possible. This is the dialectic of unconditional acceptance of clients as they are and promoting change (Linehan, 1993). Therapists can explain client and therapist roles as follows: We are not going to hammer away at your traumatic experiences session after session. I am interested in you as a whole person. You are in the driver’s seat. We will explore both past and present concerns, whatever is most important to you at the time. My job is to ensure your safety and, at the same time, support and promote your growth. Of course, that will mean helping you get in touch with painful stuff so you can work it through, here, in this safe environment, and at a pace you can handle. Your job is to let me know what you can and cannot handle.

At the beginning of therapy, clients can be asked to specify the problems they want help with, identify their goals, and discuss how therapy might help with these problems. This helps clarify expectations about the therapy process. Most processes in EFTT are fluid and responsive to situational cues so that information is provided in the context of exploring individual clients’ needs and concerns. For example, when a client complains about feeling like

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a frightened little girl in current situations, the therapist might empathize and state: It sounds like part of you is stuck in the old childhood script. From what you told me, you have never had a safe place to open up, to explore these experiences so they can evolve. That is what we are going to do here.

Make Process Observations Therapists provide feedback about client processes that are observed during sessions, and this can be thought of as a subset of providing information—for example, “I notice that you kind of withdraw whenever we start talking about your father.” These communications are distinct from interpretations because no inferences are drawn from the client’s behavior; rather, they are empirically based observations at a low level of abstraction. Nonetheless, the purpose of doing this is to invite exploration of the underlying internal processes. These observations need to be offered at a time and in a way (e.g., preceded by an empathic response) that does not increase client selfconsciousness, defensiveness, and withdrawal. Moreover, process observations provide a rationale for intervention and goals for sessions and therapy. For example, the therapist might tell the client, “By judging yourself so harshly, it must be hard to hold your head high. We want to change that and help you find a way to stand up to that internalized critic.” Provide Reassurance, Encouragement, and Hope Reassurance is intended to assuage feelings of despair and hopelessness and maintain motivation. Most trauma survivors have repeatedly tried to get over their trauma, sometimes having participated in other therapies to no avail, and consequently, they enter therapy despairing and hopeless. They also are afraid of dredging up painful feelings and memories and fear the impact this might have on their current lives. Again, the therapist needs to reassure the client that, together, they will monitor distress and coping and that the client will have maximum control over the process and pace of therapy. Encouragement is provided by genuine statements such as, “You’re not alone; I’ll help you do this” or “It’s okay; you’re doing fine.” Providing hope is also considered a critical aspect of therapy for complex trauma (Ford & Courtois, 2020). This can be accomplished in part through information about the contribution of memory work to change and the efficacy of EFTT. For example, a therapist might say, “Although there never are guarantees and there are individual differences in the degree to which people benefit, most people with similar problems to yours have benefited from this type of therapy. There is every reason to be optimistic.” Thus, clients need to be reassured that with appropriate guidance and support, people can heal the wounds of the past and move on to live meaningful lives. Clients need to feel confident in the therapist’s expertise, that the therapist understands and can

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guide them through the difficult and painful process of therapy. This reduces clients’ anxiety and increases their sense of safety so they can disclose painful material. Hope also comes through attention to client strengths, accomplishments, resilience, and internal and external resources. Foster Realistic Expectations Of course, therapists need to help their clients develop realistic expectations for change. A short-term therapy, of necessity, has a circumscribed focus and cannot solve all the client’s problems. However, provided therapy focuses on their most pressing concerns, clients can reasonably expect to make significant progress in one or two of these identified areas of concern. One of the most important questions clients ask is, “Do you ever get over it?” It is essential to communicate that they can realistically expect that childhood experiences will no longer define their life story but will be part of it. There might always be moments when recalling what happened to them will be distressing, but they will be much better able to handle that distress and put it in context. That is the therapeutic goal. For some clients, it is also useful to discuss explicitly how memory itself is somewhat malleable—a process referred to as memory reconsolidation (see Chapter 7). Although historical events of the past cannot change, the way one recalls them and feels about them and the meaning associated with those memories do change and evolve.

GOALS OF ALLIANCE FORMATION IN PHASE 1 OF EFTT The features of alliance development in EFTT are not significantly different from those in the general model of emotion-focused therapy (see Greenberg & Goldman, 2019a), except that EFTT particularly emphasizes establishing a secure attachment bond and attending to emotion regulation difficulties. These goals are interrelated and are explored in the sections that follow. Establish a Focus on Trauma Many individuals who enter therapy do so specifically to resolve issues stemming from child abuse trauma. Others have been exposed to childhood abuse but are primarily concerned with present difficulties. Still others may want to resolve past trauma but are unable to focus on a circumscribed issue from the past because of multiple ongoing stressors and severe impairments in current functioning. A decision to focus on traumatic experiences, therefore, is based on the client’s desire and capacity to do so or task markers that indicate unresolved trauma is at the root of a presenting disturbance. Establishing a trauma focus in EFTT also involves identifying the specific abusive relationships that will be the focus of therapy. Because of the prevalence of revictimization, many clients who enter therapy have experienced

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multiple forms of trauma, abuse, and neglect at the hands of multiple perpetrators. However, a short-term therapy such as EFTT requires establishing a circumscribed focus. The client, therefore, is asked to identify which issues and relationships (one or two is ideal) they find most troubling and would like to focus on in therapy. One of these should be the direct perpetrator of abuse, and the other typically is a neglectful or nonsupportive other, such as a mother who did not protect the child from abuse. Recently, we have been extending EFTT to work with refugee trauma survivors. In these instances, establishing a particular relational focus may not be a goal, or there may be an impersonal relation to a collective other (e.g., the government), political leader, or particular individual (e.g., jail guard) who is the focus of client distress. Working with refugees also sometimes presents dramatic examples of multiple traumatic experiences. However, the issues often involve overlapping losses, and a key issue in personal change is finding ways to address one’s unmet need by fostering adaptive emotion. When a specific trauma can be addressed, the individual’s feelings about themselves and what they need are typically disentangled from the specific narrative context. Thus, as one resolves one core issue, several others may become less difficult as the client brings a new experience of themself to an old set of problems. Establish a Secure Attachment Bond Establishing a secure bond between therapist and client is the fundamental task of the early phase of EFTT and is the cornerstone for the remainder of therapy. Bowlby (1988) early on emphasized that attachment needs persist throughout the life span, and adult attachment relationships serve much the same function they do in childhood. Thus, we rely on adult attachment figures to provide safety, security, support, comfort, and soothing in times of stress or distress. The therapeutic relationship meets these needs in the context of the client disclosing and exploring trauma material. The client is not alone with painful feelings and can rely on the therapist to be supportive and responsive to their feelings and needs. Therapy for interpersonal trauma that occurred during childhood development is a type of reparenting process. Thus, a secure attachment bond in the therapeutic relationship can help establish or rebuild the capacity for interpersonal connectedness that was disrupted by trauma. It is paramount to understand that EFTT is conducted in the context of a genuine and “real” relationship between adults. Traditional psychoanalytic distance and neutrality are not appropriate in this approach to treatment, and such a stance typically leads to these clients withdrawing from treatment. On the contrary, explicit expressions of interpersonal warmth are paramount. When viewing videotapes of EFTT sessions, one is struck by the quality of intimacy in the interactions: Therapists not only directly communicate compassion for their clients’ fears, struggles, suffering, and pain but may also explicitly communicate that they feel sorry that clients have suffered so much in their lives.

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Many clients who enter EFTT disclose victimization and abuse for the first time and fear that they are exposing themselves as defective or being judged by the therapist and thereby will be further humiliated and victimized (this is characteristic of shame–anxiety). Other clients have disclosed to people in the past but have had their experiences invalidated and minimized. Therapist validation of experience and empathic affirmation of vulnerability, therefore, are important responses. For example, one client (“Alan”), who we refer to in later chapters, told the story of his drunken father first breaking all the toys his mother had bought him for his birthday and then beating him for crying. The therapist’s response was, “So cruel, and so sad that a young boy should be treated like that by his own father, the person whose love he needed the most.” For many clients, this may be their first experience of receiving this type of validation and compassion, and these new interpersonal experiences are what constitute corrective emotional experiences in EFTT. In the end, therapist empathic attunement and responding strengthen the bond for both parties. In other words, as clients feel understood and cared for, therapists feel closer to their clients as well, which in turn facilitates deeper understanding and connection, a primary goal of early alliance formation. This is an area in which a focus on positive affect can play an important role in strengthening the attachment bond. Positive affect, in this case, is related to the experiences of joining, sharing, and explicitly discussing feelings of connection and celebrating client successes throughout the therapy process. Survivors of abuse and/or neglect not only have endured negative interactions with attachment figures but also have frequently missed out on other healthy relationships. Therapists can both provide and model shared positive experiences by acknowledging interpersonal connectedness, using humor, and modeling playfulness. Establish a Focus on Emotion Part of the information about the nature of trauma and recovery provided to clients concerns the central role of emotion in trauma-related disturbance—for example, trauma is an emotional disorder and damages the emotion system, and emotions are a source of information that can tell us what is wrong and guide adaptive function. Moreover, clients have learned to cope by shutting down or distrusting emotional experience and thus are disoriented. Clients learn to live in their heads, cut off not only from emotional experience but sometimes also from bodily experience—their bodies are a source of betrayal and pain. Clients in EFTT need to agree on a more holistic approach to wellbeing that includes awareness of thoughts, feelings, and bodily experience. Begin Emotion Coaching and Awareness Training While the core feature of alliance development in the early phase of EFTT is establishing a secure attachment bond, the second is increasing clients’ awareness of their emotions and emotional processes. Pioneers in the field

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of attachment (e.g., Gottman, 1997) noted the relationship between emotion awareness and attachment processes because one of the primary functions of an adult attachment figure is to help a child contain, label, and make sense of affective experience. This “emotion coaching” parenting style has been associated with many indices of superior functioning. Emotion awareness training begins in the first session of EFTT and is largely accomplished through empathic responding to client feelings and needs. From the beginning of therapy, problems are defined in terms of feelings. When clients talk about their week or past events, the therapist responds not as much to the details of the story as to their present emotional experience (e.g., “I hear what a struggle this is for you,” “So this is the worst thing in your life, the thing that still causes you so much pain”). Of course, therapists do respond to the content of trauma narrative and other material, but the focus is always on the internal experience rather than the plot and characters of what happened. In early sessions, therapists direct client attention to the core adaptive and maladaptive emotions and emotional processes (i.e., task markers) that will be the targets of therapy. Core adaptive emotions include unresolved anger at violation, betrayal, and maltreatment; sadness at losses and neglect; and the associated longings, needs, and action tendencies (e.g., a therapist might say to a client, “You’re angry at the injustice; I’m sure you’d like to see him punished for his crimes,” or “Such a huge loss; it must leave such a big ache inside”). Core maladaptive emotions include fear, anxiety, and shame, as well as the associated beliefs about self and others (e.g., “It’s like you’re not sure you can handle dredging up all that pain,” “This is terrible— to walk around feeling disposable”). Helping clients become aware of these emotional processes contributes to self-development and is the basis for developing a collaborative understanding of disturbance and the goals and tasks of therapy. For clients with limited awareness of their emotional experience, it can be helpful to direct their attention to the bodily experiences associated with specific emotions (e.g., the energy of anger, tension or trembling of anxiety, heaviness of sadness, hiding or slinking away in shame). Particularly in the early phase of therapy, this contributes to client recognition, self-monitoring, and self-control of emotion. As clients recount their reactions to situations, therapists can combine directives to attend to bodily experience (e.g., “What do you feel in your body as you think about that event?”) with empathic responses that implicitly invite clients to articulate the meaning of their experience (e.g., “You have butterflies—is there something scary about it?”). This helps clients attend to their somatic and affective experiences as sources of information that can guide them. When necessary, EFTT will also include explicit teaching about emotions, emotional processes, and the connections between emotions, thoughts, sensations, and action or behavior. This typically is integrated into the momentby-moment process of exploring current or past issues rather than presented as a separate exercise. For example, the early phase of therapy with one client

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included teaching him about the different types of anger. This was initiated at markers of defensive anger covering more vulnerable feelings of hurt and shame that the client was less aware of. Because emotions are a source of vital information that aids in adaptive functioning, the concept of alexithymia, introduced in earlier chapters, is particularly relevant here. Helping clients find the right words for their feelings is essential to the goal of increasing emotional awareness, which, in turn, is an essential part of alliance formation in EFTT. Begin to Address Emotion Regulation Difficulties Emotion regulation problems include both underregulation and overcontrol of affective experience, and both generate secondary feelings of anxiety and fear. Typical client concerns at the beginning of therapy include the following: (a) shame–anxiety, fear of negative evaluation by the therapist that results in fear of disclosure; (b) fear of their painful experience and the impact that dredging up memories will have on their current lives; (c) fear of discovering something horrible about themselves or their histories; (d) fear of failure, that therapy will not help or that it will confirm their worst fears that they are a hopeless case; and (e) particularly for clients with histories of emotional abuse and neglect, fear that their problems are not important enough, that they are exaggerating, or that there is something wrong with them for feeling so distressed (e.g., “I should really be able to get over it”). Therapists need to explicitly ask about client fears, acknowledge and validate that these concerns are normal, and then address them. EFTT therapists also observe how clients talk about themselves and traumatic experiences, their level of arousal, the degree of their openness and disclosure, their capacity for spontaneous elaboration, and so on. Once again, empathic responding in the therapeutic relationship is the primary vehicle for emotion regulation in EFTT rather than providing specific skills training. The soothing presence of the therapist, their empathic affirmation of client vulnerability, and ongoing validation help reduce isolation and distress, all of which contribute to emotion regulation. When clients are overwhelmed by emotional experience, and these standard EFTT interventions are insufficient, therapists need to draw on emotion regulation strategies from other traditions and, in some instances, teach skills that clients can use between sessions. Intensifying emotional experience typically is not the focus of Phase 1 of EFTT. However, when clients are highly constricted and overcontrolled, therapists need to identify and address these processes (e.g., “You can talk about these difficult experiences, but it seems hard for you to actually connect with the feelings”). Part of dealing with avoidance involves providing information about trauma and recovery and a rationale for focusing on painful feelings and memories presented earlier. Therapists also need to address client mis­ understandings and unrealistic beliefs about emotions (e.g., “If I start crying, I will never stop”) and label these beliefs as essentially a fear of feelings that “hold one hostage.”

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Reinforce Strengths and Resilience Client strengths and resilience stem from both internal and external resources. Internal resources include not only adaptive coping strategies but also being able to experience adaptive emotions (anger at maltreatment, sadness at loss), their associated adaptive beliefs, values, and adaptive perceptions of self and others. Research on narrative processes in psychotherapies, including EFTT, has indicated that when clients’ in-session narratives included references to these adaptive internal resources early in therapy, they had better treatment outcomes than clients whose narratives did not (Angus et al., 2013). External resources include attachment relationships, family, friends, satisfying work, spiritual beliefs, and so on. Therapists need to specifically inquire about these resources in early sessions and highlight them whenever clients refer to them or therapists observe them in therapy sessions. Collaboratively Develop Case Formulation Collaborative case formulation is an aspect of alliance formation that involves developing a mutual understanding of the factors contributing to disturbance. Such an understanding is essential to collaboration on the goals of therapy and is the rationale for all interventions used in therapy for accomplishing those goals. This understanding is based on an accurate assessment of a client’s emotional processing difficulties, which then become the targets of intervention. Such difficulties are observed in the content and quality of client narratives about upsetting events from the past and present. The only comprehensive review of the literature to date (O’Kearney & Perrott, 2006), for example, found that trauma narratives frequently contained either limited use of emotion words or overwhelming affect; were overgeneral, vague, or incoherent in terms of sequence or making sense; or were lacking in insight. These qualities of client storytelling reflect problems with encoding and processing traumatic events. This is discussed in detail in Chapter 7 on memory work. The dimensions of EFTT client case formulation or conceptualization are presented in Exhibit 4.1. Others have written extensively on case conceptualization

EXHIBIT 4.1

Dimensions of Case Conceptualization Core Maladaptive Emotion Scheme    Maladaptive emotion (fear, shame, lonely abandonment) Sense of self Perceptions of others Unmet existential needs and core negative self-evaluations Emotional Processing Difficulties (awareness, regulation, reflection, transformation) Task Markers

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from an emotion-focused therapy perspective (e.g., Goldman & Greenberg, 2015). We present a user-friendly heuristic that can aid in understanding client problems related to complex trauma. Importantly, case conceptualization is not static; it typically will evolve and be refined. Nonetheless, although further refinements will occur, by the end of Session 4, therapists and clients should have a clear understanding of the factors generating client problems. In turn, this informs accurate intervention in the next phase of therapy. Identify the Core Maladaptive Emotion Scheme As indicated in Exhibit 4.1, the first step in case conceptualization is to identify the core maladaptive emotion scheme. This may not be readily observable in clients who are avoidant or disengaged, whose storytelling is superficial, vague, overgeneral, or lacks references to feelings (Macaulay & Angus, 2019). However, through empathic exploration, maladaptive emotion schemes become evident in the unhealthy pattern of thoughts, feelings, and beliefs about self and others and the behaviors that keep them stuck. Therapists will recognize this as the “same old story” that clients want to change (Paivio & Angus, 2017). Primary maladaptive emotion. At the heart of the maladaptive emotion scheme are feelings related to fear or shame that stem from repeated threats of harm, humiliation, and neglect (see Chapter 3 on emotion subtypes). For some clients whose emotional needs were ignored or unsupported, the extent to which they experience themselves as worthless or unlovable may be unclear. In these instances, the core maladaptive emotion scheme is more one of chronic sadness, loneliness, and abandonment by others. All these emotional experiences get activated in current stressful situations where clients feel vulnerable, insecure, and unsafe. For example, a client said, “When I’m in social situations, alarm bells go off.” Another said, “I just can’t relax and trust anyone; as soon as I get close, I run away.” In other instances, where clients feel alone, uncared for, and abandoned by others, they might say, “I just feel like no one is there for me.” Because different types of abuse and neglect frequently co-occur, so do these feelings. Accurate intervention involves determining which core emotional experience is most dominant for the client— overall and at any given time. Sense of self. The fundamental component of the maladaptive emotion scheme is how clients have learned to view and treat themselves. These are problems related to self-identity, self-esteem, self-respect, and confidence. As in the model of change (Pascual-Leone & Kramer, 2019) presented in the preceding chapter (Figure 3.1), this sense of self is primarily defined by a core negative self-evaluation, essentially the meaning of the maladaptive feeling. It is not a “cognition” that drives the feeling but rather an implicit meaning within the feeling itself. Articulating this self-evaluation helps specify the corresponding unmet needs, which is another essential component of the change process (see the next section). Interventions help clients identify this self-evaluation and

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specify the adverse effects these have on their current functioning and trauma resolution. Current problems include anxious monitoring and overcontrol of self, minimizing one’s feelings and needs, and engaging in hostile self-criticism and loathing, perfectionism, or a pervasive sense of self as a powerless victim. Changing these maladaptive self-organizations so that clients have an increased capacity for openness, spontaneity, and self-acceptance is a goal of EFTT and will become the focus in Phase 2 of therapy. Perceptions of others.  The dimension of the maladaptive emotion scheme that parallels the sense of self is how clients perceive others, particularly attachment figures and intimate others. Broadly speaking, the client’s core sense of self and perceptions of others, together, compose their dominant adult attachment style or pattern (Bartholomew, 1993)—for example, being “clingy” and needy in relationships for fear of abandonment (shame-based self), longing for closeness but avoidant for fear of being hurt (insecure self), or dismissing others and extreme autonomy. During Phase 1, EFTT focuses as much on present concerns as on unresolved past issues. Clients may be caring for an aging parent they hate and cannot forgive, be unable to set boundaries and stand up to the demands of an abusive parent (or employer), have trouble being affectionate with their children, or generally have difficulties with trust and interpersonal connectedness. Not surprisingly, in the early phase of therapy, clients themselves frequently draw connections between their past experiences and current problems, and “breaking the cycle” is frequently motivation for seeking therapy in the first place. Therapists also make these connections between past and present as part of the rationale for resolving past trauma. During Phase 1 of EFTT, interventions also elicit client perceptions of those attachment figures who were perpetrators of abuse and neglect. This includes asking about a client’s understanding of others’ motives and behavior and the other’s capacity to admit wrongdoing. Initially, client perceptions tend to be globally negative (i.e., referring to the “bad other”) but become increasingly differentiated over the course of therapy. These initial perceptions are also a baseline for change and can indicate the client’s capacity for empathy, which plays a role in the resolution of relational trauma. The issue of forgiving offenders can also emerge in the early phase of therapy, and it is useful to clarify the client’s understanding of this. EFTT therapists are interested in clients’ values, wishes, and desires in this area but are not advocates of forgiveness because, empirically, this has not emerged as a requirement for resolution (Chagigiorgis & Paivio, 2006). For example, the therapist might say, “My only goal for you is that you feel better about yourself and less torn up inside.” The issue of forgiveness is also addressed in Chapter 12 on anger. Core unmet needs.  The other essential component of the maladaptive emotion scheme is core unmet needs (e.g., respect, safety, love). Referring to the model of change presented in the preceding chapter (Figure  3.1; Pascual-Leone & Kramer, 2019), unmet existential needs are juxtaposed with the client’s core

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negative self-evaluation as part of the essential meaning of maladaptive feelings. Intervention helps clients specify these unmet needs because they are vital motivating factors that inform goals for therapy and help promote change in almost all the key tasks and interventions used in EFTT. Identify Dominant Emotion Processing Difficulties As shown in Exhibit 4.1, the second major dimension of collaborative case formulation involves identifying the client’s dominant emotion processing difficulties. These underlying difficulties will emerge and need to be addressed regardless of the task and procedure being used in therapy. Emotional processing difficulties correspond to the types of emotional change processes described in the preceding chapter on emotion. These include difficulties related to (a) emotion awareness—identifying and labeling feelings (e.g., alexithymia), (b) regulation of emotional experience—both underregulation and overcontrol, (c) limited capacity for reflecting on the meaning of emotional experience, and (d) emotional transformation such that clients have limited access to adaptive emotion and associated resources that are used to promote change. Case conceptualization here involves identifying the specific adaptive experiences missing from a client’s repertoire. For example, some clients are chronically angry and have limited access to vulnerable experiences such as fear, sadness, or shame, while others may feel chronically sad, and their anger is conspicuously absent. This provides information about what needs to be activated in therapy to construct new meaning. Although processing difficulties are interrelated (e.g., clients cannot reflect on feelings they are not aware of), case conceptualization involves assessing the dominant difficulty that interferes with a client’s capacity to engage in tasks and procedures of therapy. Processing difficulties are viewed as a deeper substrate of trauma symptoms, and both need to be addressed for clients to benefit from therapy. Client emotional processing difficulties are readily identifiable in the content and quality of clients’ narrative styles regardless of the topic or task in which a client is engaged. Angus and colleagues (Angus et  al., 2017; Macaulay & Angus, 2019) identified several “problem” narrative-emotion subtypes that reflect processing difficulties typically observed in the early phase of therapy. Processing difficulties related to poor emotion awareness are evident in “empty” storytelling that is devoid of emotional content or has limited use of feeling words. Difficulties related to emotion regulation are obvious in narratives characterized by “unstoried” emotion—undifferentiated under- or overregulated arousal with unclear or incoherent meaning or content (e.g., dissociation). Limited capacity for reflection on emotional meaning is evident in “superficial” storytelling that is vague and abstract with limited internal focus. Processing difficulties related to emotional transformation are evident in client narratives that have few references to adaptive experiences to change the maladaptive emotion scheme; the client is stuck in the “same old story.” Identifying and changing the content and quality of problematic trauma narratives and storytelling is a major focus of Chapter 7 on memory work in EFTT.

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Identify Task Markers The third dimension of case conceptualization shown in Exhibit 4.1 is to identify specific task markers, the in-session client behaviors that signal specific underlying maladaptive processes which contribute to disturbance. These are the focus of complex procedures, such as two-chair dialogues, that unfold across many sessions. Markers of unfinished business with perpetrators (e.g., “I can’t get over what he did to me”) indicate a need to activate and express previously suppressed feelings and needs to resolve interpersonal trauma. Markers of client self-blame for victimization (e.g., “I should have told someone about the abuse”) or self-critical processes indicate a need to explore these internalized messages and access alternate healthy resources to challenge them and thus strengthen self-esteem. Markers of client avoidant processes indicate a need to approach and allow emotional experience before one can move forward with other processes. Clients’ lack of clarity about internal experience is yet another marker, this time indicating the need to slow down, focus on bodily experience, and verbally symbolize the meaning of experience. Therapists direct client attention to these task markers (through process observations) and explicate the underlying maladaptive processing. The first step in collaboratively identifying tasks is for clients to understand that their internal processes are contributing to disturbance and that these, rather than external circumstances or other people, are the areas over which they have the most control. Promoting clients’ agency and ability to change their internal processes is essential for self-development and self-esteem that begins in the first session. Implications for Therapy The dimensions of case conceptualization have obvious implications for the process of therapy in terms of collaborative development of broad goals and tasks, procedures for achieving goals, and interventions to address specific emotional processing difficulties within tasks. Specific goals emerge in the process of developing a collaborative understanding of the underlying determinants of client disturbance and discussions of client struggles and hopes for change.

CONDUCTING THE FIRST THREE SESSIONS Because the first three sessions are critically important in setting the course for the remainder of therapy, the following subsections provide guidelines for conducting these sessions. Structuring the Initial Sessions Therapists begin the first session of EFTT by asking clients what brought them to therapy and what they are currently struggling with or would like to change.

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This opens the door for discussing clients’ motivations for seeking therapy and any hopes and fears they may have about therapy. Again, hopes and motivations form the basis of therapeutic goals, whereas expressed fears and concerns provide the opportunity to clarify expectations and misperceptions and address fears directly. Most clients are ambivalent about being in therapy, particularly therapy for trauma, so it is important to acknowledge and validate this ambivalence. Even when clients do not admit to this, the therapist can tentatively suggest that they probably have some “mixed feelings” and nervousness about being there and name the types of anxieties that many clients have. For example, it is common for clients to feel anxious about disclosing personal and potentially embarrassing material, especially to a stranger, or being overwhelmed by painful feelings. When the therapist uses conjectures about possible client apprehension, it opens the door for discussion, clarifying expectations, and addressing specific client concerns. All the essential elements of EFTT are present in the first session. There is no distinction between assessment and treatment in terms of empathic attunement or responding to clients’ expressed or implied feelings and needs. Clients are informed that initial sessions will focus on both parties getting to know each other, feeling comfortable, and getting a clear understanding of the client’s specific problems and what is contributing to them (i.e., case conceptualization). Such an understanding will inform how therapy will proceed to address these identified problems. Typically, clients are told that later sessions will focus on helping them feel better about themselves and work through traumatic experiences, so they are no longer haunted by them, can feel more at peace, and can get on with their lives. In early sessions, it is useful to elicit client theories about their problems. Clients should be encouraged to consider, for example, the following questions: Why have problems persisted? Why do intrusive symptoms resurface? Why are angry feelings so pervasive and difficult to control? Why can’t the client sustain long-term relationships or stand up to their mother even at age 60? Not only is this the first step in arriving at a mutual understanding of the problem but it also flags possible alliance difficulties should clients have no insight into their problems or if their theory is discrepant with the treatment model. For example, clients might attribute their depression or anger control problems to external circumstances and other people. Clients need to understand that their thoughts and feelings contribute to their problems and agree that the specific goals of therapy are to address and change these internal processes. In the end, clients need to be introduced to the idea that these are the areas over which they have some control. Asking clients about their motivations for seeking therapy aids in the formulation of treatment goals. Repeated references to what clients want, what is important to them, and their values and standards help maintain motivation throughout therapy (and change maladaptive emotion schemes). Many adult survivors of complex trauma have lived for years with recurring trauma symptoms and other adverse effects. Many have also previously participated in therapies that focused on current life issues (e.g., marital distress, depression,

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substance abuse) but not explicitly on resolving past trauma or abuse. The motivation for seeking therapy explicitly to resolve trauma or abuse issues is typically triggered by distress about one’s current circumstances. These triggers frequently involve significant life changes and events, such as the birth of a child, a fear of repeating patterns of abuse or neglect with one’s own children, marital distress, divorce or maybe starting a new relationship, and dealing with an aging parent whom one hates or fears. In the initial sessions, therapists also explicitly elicit client goals for therapy— what they want to change or hope to accomplish. Clients may wish to be free of intrusive symptoms, have better relationships, or be more in touch with their feelings and connected to life. It is important to help clients be specific about how these problems interfere with their lives and envision how their lives would be better if they were free of such problems. Again, this contributes to motivation for change, is the basis for ongoing collaboration, and helps therapists stay on track in terms of client goals throughout therapy. It is essential to validate the importance of this healthy striving and assure clients that, as their therapist, you will do everything in your power to help them achieve these goals. Identifying goals at the beginning of EFTT is fluid and open-ended rather than a structured process. Because emotions are a source of information about values, concerns, and needs, they are directly related to goal setting. Empathic responses help clients establish intentions for change by highlighting the wants, needs, desires, longings, and action tendencies associated with their feelings and concerns. Goals (and more specific tasks) emerge from these personal details. For example, when a sexually abused client talks about feeling dirty, her therapist can respond to the pain of this, validate that it is not right to feel contaminated by another’s actions, and state that an important part of therapy will be to help her feel better about herself and “put the blame where it belongs.” Similarly, the therapist’s response to a client who had never disclosed his abuse to anyone was, “That’s a huge burden to carry alone; I do not want you to be alone with this stuff anymore.” This strengthens the bond by offering support and highlights the implied goal of disclosure and mutual processing. Clients typically receive these responses with tremendous relief. Assessment of client mental health and interpersonal history, as well as past and present functioning, also begins in the first session and can be approached in a loosely structured format with content areas or themes that need to be covered in the first few sessions. It also is important to assess current symptom distress (e.g., posttraumatic stress disorder, depression, anxiety) and levels of functioning because information from psychiatric diagnosis, integrated with ongoing process diagnosis, has implications for treatment. For example, Phase 2 of therapy with a client who is depressed will likely focus on understanding and alleviating their depression. It also is essential to assess clients’ current strengths and resources (both internal and external). These will affect their capacity to cope with the stress of therapy, build self-esteem, and cultivate the therapeutic bond.

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In the case of complex trauma, it is especially important to assess factors such as the age of onset, duration, types of traumatic experiences (loss, abuse, neglect), and resources and supports that were available while clients were growing up because these have implications for treatment. For example, severe abuse over a long period may be associated with greater disturbance and indicate a longer course of therapy, whereas the presence or absence of supports during a traumatic period can mitigate the extent of disturbance and, therefore, would have implications for a client’s relationship capacity and treatment success. Tentative collaborative case conceptualization begins in the first session. It is refined over the next few sessions and explicitly shared with the client at the end of Phase 1 (Session 4) as the rationale and direction for Phase 2 (e.g., “Here is my understanding of what is going on for you and what would be most helpful to start focusing on. . . . Does that make sense?”). In sharing one’s understanding of client problems with them, it is essential for therapists to use their clients’ words as much as possible when exemplifying constructs (e.g., “I think this relates to things like, when you said, ‘I feel completely disposable’”). Case conceptualization tailored to the individual client is the rationale for all intervention. The process of collaboratively developing a clear understanding of client problems occurs through therapist empathic responding that communicates understanding, immediacy, and process observations in the moment. For example, when a client describes a situation and complains that he, as an adult, is still dominated by the threat of his elderly father’s angry tirades, the therapist might respond, “It’s as if you are still chained to your father’s anger. We need to help you break that chain.” Client problems also concern the way they engage in the process of therapy. Therapists need to be transparent about the intentions underlying their interventions to address these difficulties. For example, some clients’ narrative style is one of relating long, detailed stories of external events, and they are minimally responsive to therapist empathic responses aimed at directing their attention to internal experience. In these instances, the therapist might say, “Can I interrupt for a minute? Because what you said about feeling sad is so important, we don’t want to skip over it, it’s your internal experience that we want to focus on; this is where change will take root.” When a client is unclear about how they felt in a specific situation, the therapist might offer suggestions and add, “I am making suggestions for how you might feel. See which one fits, then you can come up with your own words.” Finally, arriving at a mutual understanding of underlying determinants of disturbance may require explicitly educating clients about emotions and the effects of child abuse and trauma and providing a rationale for therapeutic intervention. For example, a client (“Paul”) whose case we refer to again in Chapter 10 was asked about his understanding of his anger control problems. Paul stated that his physically abusive father was “a bad example” and that he used anger to protect himself from ever being hurt again. This was an

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opportunity to validate Paul’s perceptions but also to educate him on different types of anger, collaborate on the goal of bypassing secondary anger (e.g., his blaming, rejecting anger and rage), and then help him access his underlying vulnerable feelings to expand his emotional repertoire. After this, whenever Paul reacted with anger to painful material, this served as a mutually recognized marker to refocus on his more vulnerable experience. Both goals and tasks emerge collaboratively from the case conceptualization. Tasks are the macrotherapeutic processes and procedures used to address processing difficulties and achieve goals. The client and therapist need to agree on the most important tasks for the client to engage in, and the client needs to agree that these tasks will be useful in achieving their personal goals. In Phase 1 of EFTT, the overarching tasks are to establish safety and trust so that clients can disclose painful and personal material and begin the process of experiencing—attending to and exploring important feelings and meanings. Although in-depth work on changing maladaptive fear and shame, reprocessing traumatic experiences, and grieving losses does not begin until a later phase of therapy, clients need to tentatively agree that engaging in these tasks will eventually help them achieve their goals. Collaboration takes place throughout therapy as new task markers emerge and new procedures for addressing these tasks are introduced. Trauma Disclosure—Telling the Story Within the relational context, the primary task during Phase 1 of EFTT is to help clients tell the story of their victimization. This topic is initiated directly by the therapist in the first session, who might ask, for example, “I know some really bad things happened to you as a child; can you tell me a bit about what happened?” Although this is not a time for deepening or reexperiencing, it is critical for therapists not to shy away from the client’s emotional pain or eliciting detailed information about the type and extent of trauma, abuse, or neglect (e.g., the therapist might ask questions such as, What exactly did he do? When did this begin? How long did it go on for? How often did this occur?). The important thing here is to empathically respond to the pain that the trauma has caused and the difficulty of dredging this material up in session with a therapist who is essentially still a stranger and acknowledge the client’s courage in doing so. The client’s process of telling the story also provides an opportunity to assess their therapeutic alliance, emotion regulation, experiencing capacities, and capacity to focus on a circumscribed issue from the past. Telling the trauma story is a form of exposure that, in EFTT, includes not only desensitization to aversive emotional triggers but also helping clients to articulate the personal meaning they make about what happened. The emphasis in EFTT is on disclosure and affirming interpersonal support and acceptance rather than desensitization to the material. Again, the therapist responds to the client’s story with compassion for their pain and suffering, empathic affirmation of their vulnerability, and validation of their experience

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and perceptions (e.g., “This is terrible,” “So sad,” “What a shame,” “That’s not right”). These types of empathic responses strengthen the attachment bond and provide security and relief. Responses that highlight core adaptive emotions of anger or sadness, for example, begin to differentiate these from global distress or upset. This develops clarity about emotional experience and begins to counter prior invalidation or minimization of traumatic experience. Responses such as, “It sounds like you missed out on so much!” encourage the client’s elaboration and help them symbolize the meaning of their emotion. Empathic responses as clients tell their story also bring to light any processing difficulties, such as problems with the underregulation of emotion. A therapist might say to the client, “Yes, I see you are feeling panicky remembering these things, like he can still hurt you. We need to help you feel less vulnerable,” or “I know hard it is to talk about these things. That’s okay; there’s no right way to do this.” This is similar for cases of emotional overcontrol. For example, a client felt guilty even at the thought of expressing anger toward her mother, who had not protected her from beatings. She explained to the therapist that she did not want to blame her mother. Therapist interventions validated and empathized with the client’s implicit desire to protect her mother and at the same time highlighted that “In the process of protecting your mom, your own feelings and needs seem to get squashed.” Two-stepped empathic responses such as this validate (and highlight) the negative impact of emotion dysregulation while, at the same time, reflecting implicit wants and desires. Moreover, they keep the focus on client goals and help maintain a client’s motivation for change. The following section focuses on alliance factors that interfere with productive client processes.

ALLIANCE DIFFICULTIES This section outlines common difficulties with the alliance, as well as therapist errors that frequently occur in the early phase of treatment, and then provides suggestions for how to address them. Some of these (e.g., a client’s self-consciousness, interpersonal control issues regarding the therapist) are issues that could occur in most kinds of psychotherapy. Established approaches to resolving similar alliance ruptures have been outlined by other experts (e.g., Elliott et al., 2004). Typically, markers for ruptures take the form of either client confrontation (e.g., challenges, criticism, anger at the therapist) or withdrawal (i.e., using passivity, distancing, nonengagement, or canceling sessions). In either case, the general process of resolving alliance ruptures begins with the therapist initiating a discussion of the observed difficulty and inviting the client to participate (e.g., “It feels like we have trouble with . . .; I noticed that . . .”). This is followed by the therapist taking a nondefensive position while both parties present their side of the problem. Next, they arrive at a shared understanding of the difficulty and address any concerns that may have led to the rupture in the first place. In the last steps of this process, the

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therapist and client identify relevant client needs that may have been at play in the rupture. Confrontation ruptures are usually related to needing more independence, whereas withdrawal ruptures are related to a client needing more support, but these need to be explored from the client’s perspective. The dyad then moves on to exploring practical solutions to the problem before moving on to productive work. The following subsections are organized in terms of the kinds of difficulties that might occur with key functions of a therapeutic alliance. We focus in particular on therapist errors that interfere with early alliance development. A Secure Attachment Bond Has Not Been Established Difficulties in establishing a secure attachment are primarily concerned with some lack of warmth and intimacy in the therapeutic relationship. These can partly be a function of the client’s attachment history and associated issues of distrust or defensiveness or their taking an externally oriented or intellectual stance that is devoid of feelings. However, difficulties establishing an attachment bond also can be a function of the therapist’s style. The traditional cool, distant, and neutral psychoanalytic stance is not helpful with survivors of childhood maltreatment. Therapists may be empathically attuned to a client’s feelings and needs, but they may not be responding enough to these observations. Often this is because they are too much in the role of the “objective clinical observer” and not emotionally involved and actively participating in the human encounter. This observer stance is not conducive to a real relationship or intimacy. Neutrality heightens clients’ anxiety, uncertainty, and self-doubt and may even resemble what they experienced in childhood. Clients with trauma histories need to know where the therapist stands, which makes transparency and genuineness crucial to establishing safety and trust. In addition, helping clients articulate their experience when they are struggling to do so is an essential part of providing support. This requires therapists to depart from the therapeutic distant stance typical of some psychodynamic models (e.g., Herman, 2019) and the Socratic style or “instructor role” that is common in cognitive and behavioral approaches to seek out a more intimate and emotionally nurturing relationship. A therapist’s reluctance to engage in this way often comes from the intention to promote client independence, but clients can perceived this as withholding. This stance also can exacerbate performance anxiety in clients who lack awareness of internal experience (e.g., alexithymia) and/or fear negative evaluation. Another therapist style to be wary of involves being overly directive. The problems of many trauma survivors stem from experiences of a profound lack of interpersonal control, which is implicit in the definition of traumatic victimization. An empathically responsive, client-centered stance that is tentative when making process directions helps restore a sense of control, reduces anxiety, and increases safety and trust. Rather than explicitly directing or

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instructing how a client should work with their content, the emphasis here is on implicitly and tentatively guiding the client’s exploratory process. Difficulties Related to a Focus on Emotional Processes Client difficulties related to emotional processes include a limited capacity to attend to, regulate, or explore affective experience. These client problems appear early in therapy and can interfere with the alliance and lead to retraumatization or dropout. For clients who are highly distressed in the first session and suffer from severe chronic anxiety in their life, the therapist can teach skills to calm and reduce distress (e.g., diaphragmatic breathing, using positive imagery). Therapists should not be overly preoccupied with maintaining a focus on emotional experience, per se, but rather with being responsive to a client’s main concerns. Any important concern is affective in nature, and, as we will see in the following chapter, focusing on concerns is a strategy for deepening experiencing step by step. With clients who are more cognitively oriented and for whom a focus on feelings seems foreign and awkward, therapists are advised to stress the client’s goals and priorities. Responses such as, “I hear how important that is to you” can be much more effective in building an alliance than responses that explicitly point at emotionality (e.g., “It sounds like you felt pretty hurt”). Similarly, therapists can help clients attend to their bodily experience as an entry point for the awareness of affective experience. Optimal therapy is characterized by flexibility in accommodating different client personalities and styles. Therapists can also be too active and not give the client enough space to explore internal experience, taking a more expert than exploratory stance. On the other side of the coin, asking highly anxious clients about feelings or meanings instead of making tentative empathic responses can increase their anxiety and precipitate shutting down and does not teach clients how to label experience accurately. Clients with difficulties attending to and exploring internal experience require considerable coaching, direction, and guidance for working with emotion. In terms of emotion regulation difficulties, at one end of the spectrum, client avoidance can be inadvertently reinforced by overly cautious therapists, who fear overwhelming the client or are overly reverent in respecting client boundaries. This misguided reticence—for example, to directly ask for details of abuse or approach emotional pain—can tacitly communicate that the content is taboo or the client is too fragile. Therefore, it is best to adopt (and model) a matter-of-fact approach that helps to counteract the client’s fear and avoidance. Toward this end, therapists must generally take the lead in helping clients approach painful and threatening material. On the other end of the spectrum, therapists who are not responsive to signs of client arousal and distress when they are disclosing painful material can exacerbate suffering. It is crucial that all efforts at approaching painful material in the early phase of therapy are productive experiences consistent with the principles of gradual exposure.

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Client Interpersonal Styles Some specific interpersonal styles and personality pathologies can also pose challenges in cultivating and maintaining a strong therapeutic relationship. Examples include extreme defensiveness and difficulties with trust, fear of negative evaluation by the therapist, performance anxiety during enactment procedures, hunger for intimacy, and high needs for therapist attunement and praise. Although abuse type and severity do not appear to be associated with outcome in EFTT, our research has indicated that severity of personality pathology can have a negative influence on in-session processes and some dimensions of client change (Paivio et al., 2010; Paivio & Nieuwenhuis, 2001). Nonetheless, this research also indicates that many clients with symptoms of personality disorder can forge reasonable working alliances and significantly benefit from therapy. This is thought to be attributable to EFTT’s unwavering emphasis on empathically responding to client feelings and needs. In the case of clients with long-standing and severe interpersonal difficulties, these feelings and needs could concern the therapeutic relationship itself. In sum, cultivating a safe and collaborative therapeutic alliance is the foundation of all other tasks and procedures in EFTT. The other primary task is promoting client attention to and exploration of internal experience (experiencing) to construct new meaning—this is the focus of the next chapter. Although a strong alliance and deep levels of client experiencing are both robust predictors of good treatment outcomes, this does not necessarily mean every client will benefit from more of everything. A recent study on EFTT showed that, by the fourth session, some clients can be identified as having difficulty in forming a strong therapeutic relationship, while others have difficulty in deepening their experience. These are distinct subgroups of clients who are at risk of not maximally benefiting from treatment (Harrington et al., 2021). Furthermore, this study showed that, for clients who had trouble developing a strong therapeutic relationship, improvement in alliance quality was the best predictor of a good outcome. However, for clients who struggled with deepening their experience, the strongest predictor of treatment outcomes was the degree to which they improved their depth of experiencing. In these instances, a strong therapeutic alliance alone was not enough to predict a good outcome. The implication here is that how a therapist balances these two key treatment processes depends on how a client initially makes use of them. This chapter has covered developing a therapeutic alliance; the following chapter focuses on how to promote client experiencing.

5 Promoting Experiencing

T

he preceding chapter focused on cultivating a safe and collaborative therapeutic alliance as a fundamental task in emotion-focused therapy for trauma (EFTT). The second fundamental task is promoting attention to and exploration of subjective internal experience (i.e., feelings and meanings) and constructing new meaning from this process. Successful engagement in all other tasks and procedures in EFTT and therapeutic outcome are dependent on these processes. One of the central tenets of EFTT is that attention to emotional experience is important because it is a source of information and meaning. Generally, the term subjective internal experience refers to the contents of emotion structures or schemes, the constituent feelings, thoughts, images, bodily sensations, and so on. Deepening client experiencing involves emotional change processes related to reflection and transformation described in the preceding chapter. Moreover, identifying processing difficulties in these areas is a part of case conceptualization that directly informs intervention. Of course, a focus on meaning construction in trauma therapy is not unique to EFTT. Different treatment approaches emphasize different aspects of meaning and different meaning construction processes, such as insight into maladaptive interpersonal patterns, restructuring of pathogenic beliefs, or rescripting trauma narratives. In the emotionfocused therapy tradition, the construct of experiencing has been used to capture and measure the quality of this meaning construction process. The experiencing construct is rooted in Rogers’s (1980) person-centered focus on the moment-by-moment process of reflecting on affective experience and

https://doi.org/10.1037/0000336-006 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  103

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more broadly refers to the process of reflecting on subjective internal experience and constructing meaning from this process. This chapter presents the unique perspective provided by the experiencing construct and the advantages of that perspective in terms of trauma recovery. We begin by defining experiencing in the context of EFTT and highlight some of the similarities and differences between EFTT and other approaches with respect to experiencing. Next, we describe the measurement of experiencing (operationalization is one of the key advantages of this construct) and give an overview of relevant research findings. The second half of the chapter describes the process of promoting experiencing as an essential component of all major tasks and procedures in EFTT. We end with the experiential “focusing” procedure and case examples.

FEATURES OF EXPERIENCING The following subsections describe features of the experiencing construct that are relevant to all trauma therapies and those that are specific to EFTT. Experiencing as a Common Change Factor There is agreement across theoretical orientations that emotional engagement with feelings and memories of trauma, rather than telling the facts of a story, is central to recovery (e.g., Cloitre et al., 2019; Foa et al., 2019, Ford & Courtois, 2020). Thus, to some extent, all exposure-based procedures are designed to promote experiencing, which can be considered part of emotional processing. Although techniques differ, exposure-based procedures are designed to activate the core emotion scheme or structure associated with the trauma and the related network of information so that it can be exposed to new information. Helping clients construct a more adaptive understanding of themselves, others, and traumatic events is the common goal. Nevertheless, we outline critical distinctions in working from an experiential and emotion-focused approach. Finally, there is considerable agreement that constructing new meaning requires the integration of information from the right-brain experiential (affective, sensory, or somatic) and left-brain conceptual and linguistic systems. These concepts are particularly relevant to trauma because traumatic experiences appear to be largely encoded holistically in right-brain “experiential memory” (Lanius et al., 2004; van der Kolk, 2015). Moreover, individuals with unresolved and unprocessed trauma (e.g., with symptoms of posttraumatic stress disorder) often have trouble making sense of and do not have adequate words for these experiences. This is evident in the impoverished quality of their trauma narratives, which can be vague, overgeneral, or incoherent. (Encoding and processing of trauma memories were discussed earlier in Chapter  1 on the nature of trauma and are discussed more fully in Chapter 7 on memory work and reexperiencing in EFTT.) It is widely believed, therefore, that recovery from trauma requires articulating the meaning of traumatic events, which occurs

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through the linking of the experiential and linguistic memory systems. Thus, experiencing always involves verbally symbolizing the meaning of traumatic experiences and, as such, is considered a core change process. EFTT Definition of Experiencing The distinct EFTT perspective on experiencing is based on the extensive writing on this construct by current emotion-focused therapy theorists (e.g., Pos & Choi, 2019). Experiencing in EFTT is both a change process and a key intervention principle. Procedures for promoting experiencing in EFTT primarily target emotion, sensory, and somatic information and help clients verbally symbolize the meaning of that internal experience. Client experience, in general, is viewed as an ongoing interaction between events in the external world and engagement with internal processes (i.e., feelings, sensations, thoughts). Thus, client moment-by-moment emotional experience, the focus of EFTT intervention, is a progressive, evolving construction that emerges from this interaction that is interpreted through self-reflection and narrative. The capacity for experiencing requires both awareness of emotion and moderate levels of emotional arousal—high enough to activate the emotion scheme or information or meaning network, but not so high as to overwhelm. Interventions increase or decrease emotional arousal as needed. Experiencing is also a process. Clients tell the story of what happened and, in so doing, attend inward to search contents of their internal experience—memories, images, beliefs, feelings, desires, values, or bodily sensations. These facets of experiential memory compose the emotion schemes that become activated (and changed) through deeper experiencing. The capacity for experiencing also requires competence in verbally articulating internal experience, and EFTT interventions enhance these competencies. Labeling and symbolization in words create distance from and, in turn, enhance regulation and understanding of emotional experience. The broader implication is that the experiencing capacity and process contribute to client agency and self-control and increases client confidence in their internal experience as a source of wisdom that can guide adaptive functioning. This is the essence of self-development.

EFTT COMPARED WITH OTHER PERSPECTIVES ON EXPERIENCING There is universal agreement in insight-oriented trauma therapies that attention to and verbal symbolization of internal subjective experience are essential to change. However, the contents that are emphasized and the means of achieving high-quality experiencing differ dramatically across perspectives. In traditional psychodynamic approaches, clients must attend to and actively experience painful feelings, make visceral contact with these in a session, and explore their conceptual meanings (Vaillant, 1994). Many recent attachment and interpersonal or relational approaches (e.g., Lowell et al., 2020) focus on clients’ current experiential meaning available to consciousness. Accelerated

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experiential dynamic psychotherapy (Fosha, 2021), which is perhaps most akin to the emotion-focused approach, emphasizes a client’s experience of the empathically responsive therapeutic relationship and how this differs from early negative attachment experiences. In EFTT, we also link current painful feelings and needs to childhood experience. However, this most typically emphasizes exploring a single experience or event in detail rather than making connections across events or identifying themes (although these may emerge). Current behavior and cognitive behavior therapy approaches to trauma also have some relevance to the construct of experiencing. In traditional exposure procedures (e.g., Foa et al., 2019), new meaning comes from being able to tolerate trauma feelings and memories and from considering new facets of the traumatic experience from a here-and-now perspective. Similarly, in eye movement desensitization and reprocessing (Shapiro, 2018), clients focus on disturbing aspects of the trauma memory and free associate. This is a private experiential search process, with the therapist guiding the process—clients create new associative links, and trauma material is thereby reprocessed. Recent cognitive constructivist and narrative approaches to therapy are similar in many ways to EFTT, especially in their focus on meaning exploration rather than the veracity of people’s interpretations (Madigan, 2019; Neimeyer, 2006). However, these approaches are more concerned with narrative content (e.g., what happened, coherence) than EFTT.

EXPERIENCING COMPARED WITH OTHER CONSTRUCTS The terms emotional processing and experiencing are sometimes used synonymously (e.g., Pos & Choi, 2019). Both constructs refer to processes that involve activating an emotion structure or scheme and modifying it by generating new information. From an emotion-focused therapy perspective, both constructs also involve capacities of emotion awareness, regulation, reflection, and transformation (see Chapter 3). However, client experiencing uniquely is operationalized (Klein et al., 1986) as a hierarchically organized process with levels or degrees that define both the content and manner of the exploration process (see Client Experiencing Scale, Appendix A). Experiencing also bears some resemblance to the construct of ego development (Loevinger, 1997), and it can be useful to think of increasing a client’s capacity for experiencing in terms of promoting ego or self-development. However, as noted earlier, the construct of experiencing refers not only to individual capacities but also to the moment-by-moment process of exploring one’s internal experience. EFTT views this process as an essential aspect of strengthening a client’s sense of self, a central focus of therapy. The constructs of mentalization and reflective functioning are also prominent in the developmental trauma field (Bateman & Fonagy, 2013). These refer to capacities to access, narrate, and reflect on one’s internal emotional experience (so frequently disrupted by childhood maltreatment) and, as such, bear some resemblance to the construct of experiencing. The construct of mentalization, however, refers to a

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broad range of capacities rather than the reflection process itself. So, a distinguishing feature of experiencing in this regard is that it is a singularly observable process of exploring internal experience, and, once again, it refers primarily to the manner of that process. Mindfulness, which has been integrated into several treatments for trauma, also has a surface-level similarity to the construct of experiencing. Mindfulness derives from Buddhist philosophy and has been adapted to Western culture and psychology (Kabat-Zinn, 1990). The wide interest in mindfulness attests to the increasing recognition across theoretical orientations that accepting internal experience is often more valuable than efforts to change it. Mindfulness is an effective emotion regulation strategy to help clients objectively observe rather than react to internal and external stimuli that generate distress. Mindfulness is a core skill taught in many third-wave approaches to cognitive and behavior therapy (e.g., Hayes et al., 2012; Linehan, 2015; Segal et al., 2013), including for complex trauma (Cloitre et al., 2019). Similarly, a recent EFT approach involved a full integration of mindfulness practices and EFT interventions (Gayner, 2019). However, mindfulness typically does not involve the exploration of meaning and is not a dialogic process. In this sense, mindfulness is “content free,” whereas client experiencing is both content focused and content specific. Thus, the aim of experiencing is to deliberately delve into the flow of visceral experience in a concerted effort to articulate its meaning verbally. In some sense, mindfulness is the skill of “moving out,” while experiencing is the skill of “moving in.” The initial levels of this moving in essentially represent purposeful emotional engagement, while deeper levels represent newly emergent feelings and meanings that address personal difficulties.

MEASUREMENT OF EXPERIENCING The construct of experiencing was behaviorally defined in the original Client Experiencing Scale (Klein et al., 1986). This scale was originally intended as a research tool, but EFTT therapists can use it as an implicit guideline for assessing the quality of client experiencing during sessions to inform case conceptualization and help track client progress over the course of therapy and thus guide intervention (see Appendix A). The Client Experiencing Scale measures (on a 7-point scale) how clients orient to their internal experience and use this material as information to resolve their problems. At low levels of experiencing, clients talk about external events with behavioral or intellectual descriptions of self and others—for example, “We were in the kitchen; it was dark; he hit me so hard my nose began to bleed; the police came; my mother was crying.” Low-level experiencing of this sort may be useful as part of an initial disclosure, but this is not considered good process and is not predictive of good treatment outcomes. This observation is consistent with trauma theory and abundant research, suggesting that emotional engagement with trauma material is predictive of outcome (Foa et al., 2019).

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As clients move to moderate levels of experiencing (i.e., Level 4), the communication concerns feelings and a personal perspective. The manner paints a portrait of the client’s internal state. This marks a turning point and is indicative of a more productive therapy process. However, although clients create a personal and affective account of events, these accounts are not yet used for self-examination. For instance, a client describing a sexual assault said, We were alone in the upstairs bedroom, and I was afraid someone would walk in, so I tried to be very quiet. When it was finally over, I felt devastated, ashamed. So, well, I just went to sleep and tried not to think about it.

At high levels of experiencing (i.e., Level 5 and above), clients explore and work through problems, propositions, or questions about the self and experiences. In the earlier example, the client might say, “I don’t understand how I could have kept it a secret for so long,” or “Maybe I’m just not a trusting person.” Feelings and meanings (e.g., causes, effects, interpretations) connected to events in clients’ lives are elaborated on and explored to resolve current problems. Self-reflection opens a new conversation about the problem imbued with new meaning. The following is an example of a client discussing her feelings toward her younger brother: CLIENT:

Being with him makes me feel anxious.

THERAPIST: Anxious? CLIENT:

Yes, I love him, but it’s like I sometimes feel angry or something . . .? And I don’t like feeling like that.

THERAPIST:

Angry—like you resent something?

CLIENT:

Yes, like I see he has everything, all the things I never had . . . [long pause]. Maybe I’m just jealous. I guess I would love to have all that, and I just know it will never happen.

Notice how, in this example, emotion is vividly and freshly experienced in the moment. The new experience is unfolding right here, right now. There is also a new understanding of personal concerns that adds depth of meaning to the experience and sometimes leads to feeling differently about a situation.

RESEARCH ON EXPERIENCING IN THERAPY In-session client experiencing is one of the few process variables that have been studied in research as a predictor of outcome for over 50 years (e.g., Kiesler, 1971). A recent meta-analysis reviewed studies that examined the relationship between client experiencing and symptom outcomes (Pascual-Leone & Yeryomenko, 2017). Around half of the studies in that meta-analysis examined emotion-focused and client-centered therapies (e.g., Pos et al., 2009), while the other half included cognitive behavioral, psychodynamic, and interpersonal treatments (Rudkin et al., 2007; Watson et al., 2011). These studies concluded that the

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process of experiencing was a significant predictor of symptom change with a small to medium effect. To put this into context: The depth of client experiencing seems to be roughly as predictive of treatment outcomes as the impact of the therapeutic alliance. Moreover, the importance of this process does not seem to be moderated by the treatment approach, suggesting the experiencing construct may represent a common change factor. Furthermore, several studies included in the Pascual-Leone and Yeryomenko (2017) review have shown that over the course of emotion-focused therapy, specifically, clients are able to increase their ability to experience deeply. Support for the value of the experiencing construct, specifically in working with trauma, comes from several other studies. For example, Holowaty and Paivio (2012) found that higher ratings of experiencing were characteristic of those therapy episodes that clients also identified in posttreatment interviews as having been most helpful. Furthermore, a process–outcome study on therapist skills in EFTT (Paivio et al., 2004) indicated that therapist adherence to EFTT intervention principles predicted client change and that the two most frequently used intervention principles were directing attention to internal experience and symbolizing the meaning of experience. This supports the value of a sustained focus on exploring the meaning of experience (or experiencing) in EFTT. Finally, client engagement, in the form of both emotional arousal and the deeper experiencing of trauma material, during imaginal confrontation was associated with the resolution of target issues related to abusive and neglectful others (Paivio et al., 2001; see also Chapter 6, this volume). The process of client experiencing and the therapeutic alliance, as discussed in the previous chapter, are both critical processes in EFTT. Furthermore, psychotherapy research seems to suggest that the more one promotes each of these, the better, but such conclusions are based on group averages. In practice, however, when a therapist is working with a specific client, there are often relative strengths and shortcomings that are observable in the degree to which a given client uses each kind of process. Research described in the preceding chapter (Harrington et al., 2021) indicated that among clients who were able to develop strong relationships early in therapy but did not experience deeply, the degree to which treatment was subsequently able to deepen the experiencing process over the course of treatment was the better predictor of symptom change. The following sections focus in depth on how therapists can facilitate the exploration of affective meaning at key moments from the beginning of therapy and through all phases of EFTT.

THE PROCESS OF DEEPENING EXPERIENCING STEP BY STEP The process of deepening experiencing begins with assessing the client’s typical experiencing level and what clients might be capable of when they are given explicit support in the way of prompts. Therapists also consider a client’s

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response to interventions (e.g., empathy, directives, questions) that are explicitly aimed at deepening experiencing. Therapists also identify emotional processing difficulties—blocks to deepening and what is interfering with the process (e.g., poor awareness of emotion or difficulties with regulation—avoidance or fear of internal experience, dysregulated emotional arousal, and incoherent narratives). This is part of case conceptualization, as described in the preceding chapter. The first consideration in promoting experiencing is to ensure that the quality of the therapeutic environment is conducive to an internally focused introspective stance. Other basic contextual factors include ensuring optimal arousal (i.e., reducing or increasing arousal as needed), an attitude of curiosity and interest in the exploratory process, and the therapist’s facilitative rather than expert stance. Experiential processing occurs spontaneously in some clients, and in these cases, the therapeutic process proceeds with minimal intervention. The client Monica presented in earlier chapters was an example of such a case. For other clients, however, difficulties with attending to and exploring internal experience are part and parcel of the presenting concerns, and therapists must continually direct and redirect attention to this process. Above all, deepening experiencing is a step-by-step process that may occur gradually over the course of several sessions or the entire course of therapy (Harrington et al., 2021; Paivio & Angus, 2017). The following sections provide guides for this process. Low to Moderate Level of Client Experiencing As noted in the section on measurement of experiencing, low levels of client experiencing are characterized by an external focus on behavior (often other people’s) and events (see Appendix A). Identifying client narrative quality is a useful lens that can guide intervention to deepen the process (Angus et al., 2019; Paivio & Angus, 2017). Low-level experiencing thus includes client narratives that have minimal emotion content or are vague, abstract, and overly general or have an overly intellectual perspective. The goal is to help shift the client narrative to one that is more personal, affective, and specific. Some clients not only have limited awareness of internal experience but also do not value it. Many social and cultural norms can be emotion phobic, and emotionality can have all kinds of negative connotations, particularly for traumatized individuals. Clients can believe, for example, that feelings necessarily involve high arousal or weakness. In these instances, it is essential to correct these misconceptions first and then provide a rationale for and explicitly collaborate on the importance of focusing on affective material. Clients need to recognize that inability to do this is an emotion processing difficulty contributing to their problems. The global intervention strategy for externally oriented storytelling involves helping the client tell a more personal and affective story. This begins with an explicit focus on the self (e.g., “That situation sounds so important to you.

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Can you tell what it is like for you on the inside when she turns her back on you like that? Do you remember what you were thinking or feeling in your heart or your body?”). When clients are unable to identify internal experience, interventions can focus on their reactions to behavior and events (e.g., “What did you do or say?”) and then tentatively connect this to their internal experience (e.g., “You walked away—you must have been pretty hurt”). When clients’ storytelling is vague and overly general, intervention should elicit specific episodic memories, beginning with whatever fragments of memory are available (e.g., “Can you give me an example? Do you remember a specific time or words he said that stick in your mind?”) to activate core emotion schemes. Similarly, global upset or distress at events and experiences needs to be differentiated into discrete emotions and the unique information associated with each. This enables the exploration of emotional meaning and thereby moves the process forward. When client narratives are overly detached and intellectual, intervention can focus on personal values and concerns (e.g., “I hear how important that event was to you. Can you tell me more? What was so important to you about that event?”). Helping clients identify their values and concerns can serve as an alternative entry point for exploring affective experience. This is because values and concerns ultimately represent core needs that are central to emotional meaning. For example, a highly intellectualized client struggled to identify his feelings about an impending separation from his girlfriend, even though he could acknowledge that this was a source of “concern.” The therapist helped him specify the concern (e.g., “So companionship is important to you”) and, in the process, helped him identify the associated affective experience (worry, loneliness), which opened further exploration of meaning. Client storytelling with minimal emotion content often indicates a lack of awareness about emotional experience. In these instances, tentative empathic conjecture whereby the therapist offers suggestions about emotional experience can be helpful (e.g., “I imagine you must feel quite resentful at times— like you can’t count on her when you need her?”). Alternately, a therapist can use disclosures about their own emotional responses to related situations or events (e.g., “If someone spoke to me like that, I would feel very hurt”) or metaphors to describe the internal experience (“I would want to crawl in hole and disappear”). For clients who have difficulties identifying and labeling feelings (e.g., alexithymia), interventions involve explicit emotion coaching—providing information about normal human emotions and guidance and direction in labeling emotion. This can begin with attention to bodily experience and the connection between sensation and emotion (e.g., “This knot in your stomach—something has got you tied up in knots like you are worried about something?”). Clients at the more extreme end of the spectrum, who also have limited awareness of bodily experience (i.e., colloquially referred to as “dead from the neck down”), will also benefit from cultivating more physical body awareness through practices such as mindfulness or yoga.

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Moderate to High Level of Client Experiencing Experiential storytelling is specific, personal, affective, and sensorial (Angus et al., 2019; Paivio & Angus, 2017). This type of processing is a turning point because it provides entry to emotion schemes and an associated network of information. Thus, moderate levels of experiencing (Level 4 in Appendix A) are characterized by narratives that are affective and personal or use metaphors but do not yet include reflection on affective experience. This is easier to work with than externally focused storytelling because there is at least a window into the client’s internal life as a starting point for exploration. The goal is to access specific emotions, promote reflection on internal experience, pose questions about self, and explore meaning (shift to Level 5). Intervention to deepen moderate level experiencing involves identifying implied feelings and meanings associated with the client narrative or metaphor. For example, the client Marianne described herself as a “little girl in a dungeon.” The therapist empathically responded to the implied feelings, “That’s very sad, a little girl in a dungeon—feeling what? Lonely?” The client responded, “Like you said before, helpless.” This opened the door for further exploration. (The case of Marianne is presented in Chapter 8.) Another client describing her mother said, “She’s the adult; she should be looking after that, not me!” The therapist responded to the client’s intended message, “I hear how much you resent being saddled with that burden—almost being her mother rather than the other way around. I imagine you would love some mothering of your own at times.” In some instances, the client narrative contains emotion words, and the client is aware of emotional experience, but those verbal labels come with low arousal. For example, the client Mark (who we return to in a later chapter) expressed anger toward his mother—“I hate her”—in a flat, matter-of-fact tone. Here, evocative empathy (e.g., “You ‘hate’ her—wow, that really burns!”) or other evocative procedures (e.g., “Say it again,” “Say it louder”) can increase arousal and activate associated information for exploration. For Mark, evocation involved imagining his mother in an imaginal confrontation (described in the next chapter) and enacting her tone of voice—“It’s like a knife digging a hole in my heart”—which increased emotional arousal and activated the core emotion scheme for exploration. When clients can identify feelings and emotional arousal is moderate, interventions to deepen experiencing should explore the meaning of feelings. Meaning includes the causes of distress, views of self and others, the effects of behavior and events on self or relationships, and especially, one’s unmet needs. The latter is particularly important because needs offer a motivational bridge to activate healthy resources to transform maladaptive emotion schemes. Finally, shifting from moderate to higher, more reflective levels of experiencing involves explicitly identifying problems about self and one’s struggle to change them (e.g., to resolve issues with perpetrators, assert interpersonal

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boundaries, stop blaming oneself for abuse). To do this, interventions should focus on core wants, needs, desires, and blocks to achieving them. For example, the therapist might say to an anxious client, “A part of you wants to be more open, but I understand you are afraid—you don’t know the impact of being open on yourself and how others will react.” This is the basis and rationale for continued therapeutic intervention to better understand and reduce blocks.

High to Highest Level of Client Experiencing At high levels of experiencing, clients are reflective, exploring the self and their problems. At the highest levels of experiencing (Levels 6 and 7 in Appendix A), clients are engaged in the process of change—answering questions about the self, constructing a new understanding of problems, and making sense of previously confusing or unclear experiences. This is the process of emotional transformation. For example, the client Monica shifted from not understanding her mother’s suicide in early sessions to later being able to imagine that her mother was disturbed and felt trapped and hopeless. This, along with accessing positive memories of her mother, helped her forgive her mother at the end of therapy. Interventions aimed at constructing new meaning described in later chapters (e.g., imaginal confrontations, reexperiencing trauma memories, twochair dialogues between parts of self) help clients to explore the struggle to change (e.g., to forgive perpetrators or self, to trust one’s perceptions) and highlight subdominant healthy resources (feelings, beliefs, needs, behaviors) that can be used in that process. Interventions help clients identify and increase experiential awareness of these resources and the positive outcomes that emerge from engaging these adaptive feelings and needs (e.g., forgiveness, self-compassion). The highest level of experiencing also involves connecting specific problems and new understanding to a broader meaning and one’s overall life story. For example, a client at the end of therapy said, If I know what I want, I am better able to assert my boundaries with my mother. I can tell her I want her in my life, but if she refuses to respect me, even though it will kill me to end it, I am not willing to have a relationship with her.

The therapist directed her attention to positive feelings associated with this stance to deepen experiential awareness and consolidate change. The process of deepening client experience is ubiquitous in emotion-focused therapy and will be seamlessly integrated, either in whole or in part, within most of the major interventions. However, in the following sections, we describe a structured and self-contained procedure explicitly aimed at deepening experiencing. Steps in this procedure presented in the following section can serve as a guide to the experiencing process in general.

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GUIDELINES FOR THE STRUCTURED FOCUSING PROCEDURE Gendlin (1996) developed the focusing method for systematically, step by step, helping clients attend to and verbally symbolize the meaning of bodily felt experience. Accordingly, the personal meaning of a client’s unfolding story flows from bodily or visceral experience that is then translated into words and elaborated. Focusing is successful when clients synthesize various aspects of their immediate psychophysical experience with their linguistic-based understanding and capture in words an aspect of their subjective world that was previously unclear. Since Gendlin’s early work, there has been increasing interest in this approach. For example, some cognitive behavior therapy approaches incorporate abbreviated or modified versions of this procedure to reduce client confusion about their internal experience and thereby reduce anxiety (e.g., Marks et al., 2019). The focusing procedure can be used systematically in EFTT to teach the skill of experiencing, or individual components (e.g., finding words to describe bodily experience) can be used piecemeal as needed. The basic principles of focusing (deepening experiencing or emotional processing) are implicitly incorporated into most of the major EFTT procedures described in later chapters. Focusing is specifically indicated when clients are unclear or confused about their feelings regarding some past or present situation or circumstance. The following steps in the process are illustrated with a client, Lin, who came to EFTT to deal with anxiety that seemed to stem from harsh parenting involving emotional and physical abuse. She had a history of acquiescing to parental demands, suppressing her feelings and needs, and this pattern played out in her current interpersonal relationship. Lin’s narrative style was highly intellectual, and she had significant difficulties identifying and labeling her emotional experience (i.e., alexithymia). This interfered with her capacity for experiencing in session and thus her ability to benefit from EFTT. Lin also had a history of parasuicide attempts when she was a teenager, which she acknowledged were efforts to tell her mother how much she was hurting. Lin came to Session 3 feeling highly anxious but not knowing why. This was a marker for introducing the focusing procedure to help her clarify her experience and potentially increase her capacity for experiencing in general. Step 1: Relaxation, Calming, and Freeing the Mind of Distractions The first step in focusing resembles many meditation practices. Once clients agree to spend time understanding their experience, they can be guided through standard breathing or progressive muscle relaxation exercises (as needed) and encouraged to free their minds of distractions and gently focus their attention inward with no pressure or force, “just noticing.” For clients who have difficulty regulating their emotions, learning to relax and free their minds of distractions may be an important treatment goal in and of itself. However, for clients who can tolerate difficult or ambiguous feelings

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and for whom the goal is to facilitate deeper experiencing, the subsequent focusing steps will help carry the process forward. Step 2: Attending to Bodily Felt Experience Once relaxed, clients are then instructed to attend inward to “that place in your body where you feel your feelings” or to the specific sensation or felt experience they have identified. They are encouraged to attend to the entirety of the experience, “the whole of it,” rather than to analyze the experience. Sometimes clients are only aware of feeling overwhelmed, “dead,” or “blank” inside, but if they can patiently attend to the flow of this experience, things inevitably evolve, and one specific issue will become more salient. It is essential to help clients cultivate an attitude of receptiveness and let things naturally evolve, not exert effort to find answers or figure anything out. Alternately, if clients can identify a particular issue they find troubling, they can be directed to focus on the bodily felt sense of that issue. When clients feel overwhelmed by multiple issues, the therapist can encourage them to focus on one thing at a time (e.g., “Pick one problem for now and push the other issues aside, just for the time being”). For example, after a short period of deep breathing and muscle relaxation, the client Lin became aware of tension in her neck and shoulders. The therapist encouraged her to follow the sensations and suggested that this tension could be a function of needing further relaxation rather than a topic of exploration. She encouraged Lin to breathe into her shoulders, lengthening her out-breath and letting go of any residual tension and, at the same time, continue to focus on and observe that experience in her body. Step 3: Finding the Right Words Once clients are directed inward toward an unclear felt sense, they arrive at the task of finding the right words to describe it. Therapists can help by guiding clients to search for and check potential descriptors for this experience (e.g., “What is the quality of that feeling or sensation in your chest? Is there a word, phrase, or image that seems to fit?”). However, clients should be encouraged to avoid describing their experience from the outside looking in and avoid interpreting or explaining their experience. Rather, they should speak from the experience. It is worth noting that interventions in gestalt therapy similarly encourage clients to “be” that aspect of self (e.g., “If your gut [or fist] could speak, what would it say?” or “Put words to your tears”). This type of bottom-up processing is characterized by a tentative and uncertain quality as clients search for and experiment with finding just the right words. Therapist empathic responses that stay close to the client’s words and avoid any form of conjecture or interpretation will facilitate this process. Empathic responses maintain contact with the client, communicate understanding, and function like a mirror to promote reflective clarity. The process of finding the

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right words involves shifting back and forth between the descriptor or image and the felt sense itself. This is a way of checking the “fit” and adjusting to find the right match between the experience and the verbal or imagistic representation. This resembles the tip-of-the-tongue phenomenon in which one tries out different words in an effort toward better symbolization. The correct descriptor or “handle” is immediately recognizable once it is found. The co-exploration process continues until this occurs. Lin, with her eyes closed, referred to the tension that shifted to her stomach: THERAPIST:

Okay, it shifts—stay with that; can you describe that feeling in your stomach?

CLIENT: [pauses] It’s like protection. THERAPIST:

Does that feel right—that you are somehow protecting yourself?

CLIENT:

It’s like a shield at first. But as I relax more, it’s like a pit in my stomach.

THERAPIST:

A “pit”—stay with that pit. Can you say more? Don’t explain it; just let the “pit” speak.

CLIENT: [pauses] It’s like a feeling of “dread.” THERAPIST:

“Dread” . . . okay. Go back and forth between the word “dread” and that sensation in your stomach—check if it fits.

CLIENT: [pauses] Yes. Like something bad is going to happen. THERAPIST:

Stay with that—say more. Like something bad is looming? [evocative empathy]

Here, the therapist’s use of evocative empathy helps Lin shift to deeper levels of experiencing and begins the exploration of its meaning. Step 4: Exploring the Experience Once a client has tentatively identified a “handle” that seems to capture the essence of that felt sense, interventions help them explore further by reflecting on the role of this experience with respect to their values, goals, or life. This step is referred to as “asking” because it involves contemplating questions that extend beyond the initial symbolization. Exploratory questions or empathic responses nudge the client to expand their awareness and deepen experiencing. At this point, Lin described her fear of failing an upcoming exam for her law degree. THERAPIST: Ah, so that’s the dread: failing the exam. Can you allow the

dread to speak to you? CLIENT:

It’s like, “Lin, you are not working hard enough . . . you are going to fail . . . not as good as my colleagues. . . . Everyone will pass and move on but me. I will be the only one who fails.”

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THERAPIST:

Oh, that’s awful—the only one.

CLIENT:

It makes me sweat just thinking about it.

THERAPIST:

[validates] Yes, of course, very scary.

It is not uncommon for survivors of harsh parenting, like Lin, who coped by suppressing difficult experiences, to have trouble allowing and accepting such experiences when they emerge in the context of focusing. In these instances, interventions must validate and affirm the client’s difficulty to reduce anxiety and then encourage further exploration: CLIENT: [wiping perspiration from her forehead] It’s only sweat; I’m not

connected with it. THERAPIST:

Mmm, it’s an awful feeling—you don’t want to feel it?

CLIENT:

I’m pushing it away.

THERAPIST:

Pushing it away—hugely painful. This is kind of a huge assault on your self-esteem.

CLIENT:

Very scary.

THERAPIST: I understand that part of you is trying to push it away. Is it

okay if we try and get a little closer? Because it seems like that is an important part of what is going on for you right now—it’s affecting your sense of self. CLIENT:

Yes, very scary.

THERAPIST:

That sense that Lin is not up to par, not as good as her friends, will be left behind.

Thus, the therapist encourages Lin to bypass her self-interruption. (Sometimes, self-interruptive and avoidance processes cannot be so easily bypassed; a later chapter on fear and avoidance addresses that.) Step 5: Elaborating and Accepting The goal here is to expand the information network and integrate the nowsymbolized experience into the client’s existing perspectives, which is the broader context of their life. Just as a well-attuned therapist closely tracks the client’s process, clients themselves must be encouraged to track their own evolving experience (e.g., the therapist might say, “Stay with that feeling; observe the flow”) and then communicate their emerging understandings. Therapists’ empathic responses, in turn, communicate understanding and encourage further elaboration. This typically begins a shift from engagement in a structured procedure to exploring the core issue in the normal dialogic interaction with the therapist. Lin’s concern shifted to her current romantic relationship, which was interfering with her ability to study for exams. The therapist validated and empathized with that concern and, again, helped Lin to explore the meaning of her

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experience. Again, Lin interrupted her emotional experience, and again, the therapist encouraged her to approach rather than distance herself from the difficult feelings that emerged. THERAPIST: That sounds like a very important relationship to you . . .

wanting to spend as much time as possible with him. CLIENT:

When I start thinking about it, I start sweating again.

THERAPIST:

What is that sweat telling you?

CLIENT:

That I don’t want to talk about it; it makes me unhappy, scared?

THERAPIST: Okay, scared, so don’t think about it; push it away, push it

away, keep it all inside. CLIENT:

Yes, keep it all to the side.

THERAPIST:

Keep it all to the side. But somehow, it keeps intruding, interfering with your ability to concentrate, intruding on your life. It’s hard to keep it compartmentalized [process observation].

CLIENT:

Yes, it is affecting my life.

THERAPIST:

So, this is a big deal, this relationship. You care a lot about him. But something is not right?

CLIENT:

It’s a very big deal.

Lin then disclosed her fear that her feelings are not reciprocated, that she is giving more than she is getting. The therapist used evocative empathy to activate core emotions (sadness and anger) and deepen the exploration process, which shifted to the highest levels of experiencing. THERAPIST:

So, you are settling for whatever he will give?

CLIENT:

Yes [eyes well up in tears].

THERAPIST: I see that makes you feel sad. You are not getting what you

want, but are you getting enough? CLIENT:

No, I am not getting enough. . . . I feel used. . . . I feel like I’m just a joyride.

THERAPIST:

A joyride—that doesn’t feel good! You must resent being used like that.

Here, empathic responding accessed adaptive anger to change the same old pattern of acquiescing to others, squashing her feelings and needs, to help her acknowledge and feel entitled to her unmet needs (for love and respect) and motivate adaptive behavior. Step 6: Bridging to Life The final stage in the focusing procedure is to bridge to a broader meaning and implications for the broader context of the client’s life. At the end of session, Lin understood her anxiety and where she stood in her romantic relationship. During the following week, she confronted her boyfriend with her feelings and

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felt good that she was able to clearly express her resentment without bitterness and her desire for a more reciprocal relationship and accept that this might not happen despite her wishes. She felt good about herself for being able to say where she stands regardless of the outcome. Lin also reported understanding, for the first time, the value of her emotional experience in understanding and resolving her problems. She and her therapist continued to use the structured focusing procedure as needed in therapy. This significantly improved her ability to attend to, explore, and understand her emotional experience. Later sessions focused on helping Lin identify and express her feelings and needs, particularly in relation to her emotionally and physically abusive mother, and productively engage in the imaginal confrontation procedure (see the next chapter). Finally, even though there is variability in clients’ capacities for experiencing, it is essential to treat experiencing as a capacity that can be improved with practice—collaboration on the goal to improve this capacity is the first step. When clients find experiencing difficult, the therapist should enlist their permission to redirect their attention inward. Clients who like homework can be encouraged to practice focusing between sessions. Focusing Principles Integrated Into the Therapy Process The following is an example of an exploratory process to help a client understand her confusing feelings toward her abusive and neglectful alcoholic mother. This case was originally presented in Paivio and Angus (2017). The following episode took place during Session 6 and illustrates how principles of focusing can be integrated into any phase of therapy. In this example, the therapist invites exploration but, unlike the structured focusing procedure described earlier, the process does not begin with guiding the client through breathing or progressive muscle relaxation exercises to free their mind (Step 1) or with directives to explicitly focus on a bodily felt sense (Step 2). In the following excerpt, the therapist invites exploration of the client’s unclear feelings toward her mother and helps the client shift to a more affective and reflective stance. THERAPIST:

Okay, so what could she [the mother] do or not do that would make you want to draw closer to her?

CLIENT:

Not need me [thoughtful, exploratory, searching internal experience]. But, I mean, she couldn’t have done anything because she took up all the space.

THERAPIST:

Mm-hmm. How did she do that? [promote specificity and further exploration]

CLIENT:

It was a feeling thing, this neediness.

THERAPIST:

So, there was a neediness—like wanting something? What did she do exactly? [silent, thoughtful] I know it’s hard to put into words. . . .

CLIENT:

Wow, words for this! Because she didn’t DO anything. She was always saying how beautiful I was and how smart I was, and I liked that, but hearing it was [pauses, searching], it’s like she’s

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too focused on me or something? [pauses, shaking head, searching inside] How did she fill up all that space? So that it would make me turn away? This lack of clarity is an indicator of the continued exploration of her internal experience in a search for understanding and meaning. The therapist is attentive, following and offering minimal encouragers as the client searches and focuses on her internal experience, especially her needs in past situations with her mother. CLIENT:

It’s like her whole being . . . the only thing I can come up with is I didn’t like who she was [silence, internal focus].

THERAPIST:

If we stick with the things you have identified, it’s almost like in every gesture, you felt this neediness coming from her, and you felt this desire to create space?

Here, the therapist is providing scaffolding to the client’s search for words and invites the client to reflect further, guiding the process while leaving the content to the client. CLIENT:

Yes, it was. First, I was going to be a secretary, nurse, artist, etc.—no space for me.

THERAPIST:

Sounds like . . . molding your identity or . . . intrusive. . . .

CLIENT:

Very, it would be like her trying to BE me, trying to get in my back and move my arms and my head and . . .

Here, the client enacted a puppet-like movement, and this enacted image became a “handle” for better understanding the implicit meaning going forward. THERAPIST:

Just controlling everything you do.

At this point, the coconstructive process resulted in emerging new understanding, new meaning (the highest level of experiencing), self-awareness, and self-narrative change. CLIENT:

Yes! So that’s controlling, getting in, and directing; of course, it is. I never put that word to it. So, this is what I mean how I never had a chance to know how I felt, be myself.

In this example, the focusing and experiencing process unfolds smoothly, and the client is responsive to therapist intervention. The following section describes EFTT intervention when clients are having difficulties with experiencing, including with the focusing procedure.

DIFFICULTIES WITH EXPERIENCING Many clients with histories of childhood trauma have spent a lifetime distancing themselves from internal experience. They do not know how to explore internal experience and may be afraid of doing so. Low-level experiencing is

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their habitual way of operating, and they will repeatedly return to this familiar mode of engagement. To address this challenge, therapists must first ensure that the basics are in place and that the therapeutic “environment” is conducive to an inward focus and reflection. Concretely, this means the therapist uses a tentative and curious vocal quality, a slow pace, and an exploratory rather than solution-oriented intention. The therapist also must ensure the client understands and agrees about the value of the task and essentially have their clients’ permission to repeatedly redirect the process to an internally focused exploratory stance. Offer Patience, Persistence, and Consistency in Directing Client Attention Inward It is important to have patience and realistic expectations. Interventions may help clients momentarily shift to a more internal stance even though externally oriented clients typically will return to their focus on plot and characters because it is a more familiar mode of processing and less stressful. Therapists need to listen for the right moment, be selective, and intervene at the most poignant part of the client’s story. It is important to avoid a power struggle or battle between therapist and client but, at the same time, to be persistent and consistent, intervene regularly, and not let the client drift into external storytelling. An experientially attuned therapist will attend to when clients make this type of deflection and then gently guide them back to feelings and meanings. Therapists who are reluctant to interrupt their clients should not be afraid to say, “Can I interrupt? You said a lot, and I don’t want to lose track. Can we go back to . . .,” or “Your perspective is so important; let’s slow down and really understand it better to help you really taste the importance of it.” The therapist could also experiment with beginning every session with a form of focusing to reorient clients who respond well to this and need more structure. Offer Emotion Coaching in the Context of the Moment-by-Moment Process Therapists provide process observations about client difficulties with experiencing, a rationale and transparency about therapist intentions, and directions and guidance for deepening experiencing as difficulties emerge in the momentby-moment process. For example, a client who was experiencing marital distress continued to focus on his wife’s behavior, despite the therapist’s attempts to deepen his experiencing. He would respond briefly to therapist interventions (empathic responses, questions, directives) intended to direct his attention to his internal experience but then quickly deflect back to focusing on his wife. When this occurred again in session, the therapist responded, Can we stop for a minute, Karl? I see how difficult it is for you to deal with your wife’s behavior. However, focusing on her behavior in session often is at the expense of attending to your feelings and needs. When I ask about your experience in that situation, it’s because we need to know what goes on for YOU on the inside in those difficult interactions so that you can change them.

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This intervention offered when the client’s storytelling is emotionally alive is more effective in deepening experiencing than psychoeducation or waiting to summarize at the beginning or end of a session. Similarly, the therapist may need to provide explicit directives and guidance for slowing down (e.g., grounding in the present, balanced breathing) so that internal experience can be explored and information about the nature of internal experience (e.g., the connection between thoughts, feelings, sensations) gathered. These directives and information should be provided when a specific internal experience is activated in the moment. Provide an “Experience” of the Value of Experiencing, Not Just Education Evocative empathic responses and imagery techniques, described in later chapters, that evoke client pain as a child in response to fleeting moments of experiencing can be particularly helpful. These can deeply touch the heart of the matter and help the client feel the personal importance of their concerns. These responses also help clients feel seen, reduce isolation, and create a valued connection with the therapist. For example, the client Paul’s processing style was overly rational and intellectual. At the beginning of Session 12, Paul reported that it was his birthday, and no one had called to wish him a happy birthday. When the therapist empathically responded, “Wow, so sad—feeling like that lonely little boy, no one even remembering his birthday,” the client cried for the first time in therapy. The therapist also validated Paul’s expressed concern about feeling so raw and vulnerable in the moment but also provided support and encouragement: “I feel happy for you, Paul. You are changing. This is who you are; you are getting to know a part of yourself you didn’t know before. And I feel closer to you when you are open.” The quality of therapy changed following that session. In another example, the client, Tina (presented in Chapter 9), whose narrative style was externally and behaviorally focused, described herself as a matterof-fact, unemotional person. The therapist validated this “squashing” of her emotional experience as a part of the “damage” done by childhood abuse and invited the client to imagine herself as a little girl in the chair across from her. This evoked the client’s tears in response to a memory of herself alone in her room, wishing she had a different mother. From this experience of sadness for self, she affirmed her entitlement to unmet needs: “I definitely deserved more happiness.” This was an entirely new therapeutic experience that she valued and opened the door to further self-exploration and awareness. The commonality among these in-session examples is that the events are client experiences that lead to a lived insight rather than providing an instructional lesson. Empathically Respond or Ask Specific Questions Clients who suffer from performance anxiety can feel “put on the spot,” afraid they will not have the correct answer, and they shut down when asked about their internal experience. Empathic conjecture (e.g., “I imagine,” “If it were

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me, I would feel so . . .”) helps reduce the client’s ambiguity and anxiety. Similarly, specific questions (e.g., “How are you reacting to what I just said— does it make sense? Any thoughts triggered? Or feelings?”) rather than openended questions (e.g., “What is going on for you right now?”) are more helpful. Intervention also could include validation and brief emotion regulation strategies, such as a directive to “breathe,” to help reduce client anxiety. Acknowledge, Validate, and Affirm Vulnerability Before Exploring When clients are feeling extremely vulnerable, nervous, or ashamed about emerging experience—for example, when they are disclosing instances of sexual abuse or other humiliation—the therapist needs to affirm their vulnerability (e.g., “Yes, I’m sure it feels like a huge risk even just to mention it”). Moreover, the sense of vulnerability will have to decrease before the experience can be examined. Many survivors of complex trauma are uncertain about whether their feelings and perspectives are legitimate or normal. When this is the explicit or implicit client message, therapists need to validate their client’s feelings or perspectives before inviting exploration (e.g., “Of course you’re nervous—you’ve never talked about this stuff before”). Address Clients’ Silent Withdrawal Sometimes clients withdraw within session with an awkward and tense quality, in a way that suggests it is more than just a lull in the conversation. When therapists enquire about this, clients typically have difficulty articulating or seem reluctant to share their experience. Intervention to work through this involves collaboratively assessing the reason for the silence and drawing the client out, helping them reengage with the therapeutic process. Silences of this kind should be acknowledged and are best addressed by the therapist tentatively conjecturing about the implicit meanings of the silence (e.g., “I get the sense you have withdrawn, moved far away from here [or me],” or “It seems like you’ve gone blank, like you’ve somehow shut down?”). For example, one EFTT client was chatty and engaging when discussions concerned her daily life but was completely silent in response to empathic exploration or questions that concerned her sexual abuse by several male relatives. This continued for several sessions. It took considerable patience on the part of the therapist and persistence in empathizing with how difficult engaging in therapy must be (e.g., “It must be hard to talk about these experiences,” “How lonely it must be for you to be shut up inside,” “I imagine you wish the whole thing would just go away”). These empathic conjectures were important in building trust and initiating an exploratory attitude in session. At the midpoint of therapy, the client began to open up about her internal experience, which then allowed for deeper therapeutic work. The process of deepening emotional processing or experiencing in EFTT is first contingent on clients’ capacities for awareness and regulation of emotion. These are the necessary foundation for further processing through reflection on

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emotional meaning and constructing new meaning by integrating adaptive emotion and associated information to modify maladaptive emotion schemes or change the “same old story.” This is the essence of emotional transformation regardless of the procedure. In sum, promoting experiencing begins in the first session as clients are encouraged to attend to their internal experience, articulate the meaning of the troubling situations that brought them to therapy, explore their hopes and fears concerning the therapy process itself, and identify therapeutic goals. Promotion of experiencing is fundamental to all tasks and procedures used in later sessions over the course of therapy. The following chapter introducing the imaginal confrontation procedure begins the transition from the early to the middle phase of EFTT.

6 The Imaginal Confrontation Procedure

O

nce a secure attachment bond and a focus on internal experience have been established, it is time to begin in-depth trauma work with the introduction of the imaginal confrontation (IC) procedure. As noted in an earlier chapter, IC generally resembles the gestalt-derived empty-chair dialogue for resolving “unfinished business,” a basic intervention used in emotion-focused therapy (e.g., Greenberg & Goldman, 2019a; Paivio & Greenberg, 1995). The new IC terminology places this procedure in the specific context of trauma therapies, emphasizes its affinity to other exposure-based procedures, and focuses on the confrontational nature of trauma exposure. During IC, the client imagines an offender in an empty chair and expresses evoked thoughts and feelings directly to this imagined other, imagines or enacts the other’s reactions to their expressions, and thereby engages in a dialogue with the imagined other. In this context, the client explores their shifting perceptions of self, other, and traumatic events. Although IC involves exposure-based processes, explicitly reexperiencing trauma memories is also a separate stand-alone procedure that is discussed in the following chapter. The introduction of IC usually takes place during Session 4. Seminal research on emotion-focused therapy for trauma (EFTT) indicated that both emotional engagement with trauma material during IC and the quality of the alliance early in therapy each independently contribute to client change (Paivio et al., 2001, 2004). There also is a reciprocal relationship between these variables such

https://doi.org/10.1037/0000336-007 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  125

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that they overlap on the task agreement dimension of the alliance. The more clients agree on the value of core interventions, the better they can engage in them and vice versa. Thus, a strong alliance at Session 3 predicts productive engagement in IC at Session 4, which, in turn, strengthens the alliance and predicts the quality of subsequent trauma exploration and a positive treatment outcome. In this chapter, we outline the features and intervention principles relevant to IC, describe process measures that can be used to assess clients’ progress through the resolution process, and review research on the client and therapist characteristics related to successful engagement in IC. This is followed by a detailed description of client processes and therapist operations during each step of the IC procedure, providing a road map of both short- and long-term goals. We also review those aspects of the therapeutic relationship that are critical to the successful introduction and implementation of IC. Finally, we elaborate on the use of the evocative exploration procedure (which is essentially IC without the empty-chair dialogue) as an alternative for clients who cannot or will not engage in IC. The chapter concludes with a section on other strategies, in addition to evocative exploration, for addressing client difficulties during IC.

IC OF PERPETRATORS Although imaginarily confronting perpetrators can be stressful, individuals learn that they can tolerate painful feelings and memories and develop a new understanding of traumatic experiences by telling and retelling the story of their victimization. Research supports the efficacy of exposure-based therapies with diverse traumatized populations, including survivors of complex relational trauma (see Ford & Courtois, 2020). Early research on EFTT has indicated that emotional engagement with trauma material during IC (assessed through observations of videotaped therapy sessions) contributed to multiple dimensions of client change and had independent benefits beyond the quality of the alliance (Paivio et al., 2001). When both the quality of engagement and the frequency of participation over the course of therapy were considered, IC was associated with a host of improvements, including reduced trauma symptoms, global symptom distress, and interpersonal problems, as well as improved self-esteem. Furthermore, among those clients who made clinically significant improvements, more were classified as highly engaged during IC than those who had low levels of engagement (71% vs. 39% recovered). The independent contribution of “dosage” of IC (frequency of task × quality of engagement) to reduced trauma symptoms supports the posited role of this procedure in the emotional processing of trauma memories. The contribution of dosage to reduced trauma symptoms is consistent with the effect of habituation processes cited in the literature (Foa et al., 2019). The additional contribution of dosage to reduced global symptom

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distress and interpersonal problems further suggests that the repeated confrontation of specific perpetrators generalized to more global dimensions of change. IC in EFTT Compared With Other Exposure-Based Procedures Exposure procedures described in the literature range from clients simply telling their stories of victimization to more structured approaches that incorporate aspects of prolonged exposure. These are more thoroughly reviewed in the following chapter on memory work and reexperiencing. Although specific techniques differ, in general, exposure systematically encourages clients to focus internally on troublesome aspects of trauma memories. When these stories are richly told, this facilitates attention to multimodal aspects of experience. Therapists monitor their clients’ level of distress, acknowledging and accepting the emergence of any maladaptive beliefs or perceptions (e.g., selfblame). These continue to be processed until a shift occurs—distress decreases, and new adaptive information emerges (e.g., perceptions of self as blameless). Because traumatic events are thought to be largely encoded in experiential memory (van der Kolk, 2015), reliving procedures used in all therapeutic approaches are intended to evoke experiential memories that include feelings, sounds, smells, images, and bodily experience. Once activated in therapy, emotional material is available for exploration, working through, emotional processing, and change, consistent with the neuroscience of emotional change (Lane & Nadel, 2020; Pascual-Leone & Greenberg, 2020). IC used in EFTT is a systematically implemented procedure that includes elements of exposure. Specific trauma memories may emerge or be evoked in the context of imaginarily confronting perpetrators of abuse and neglect; however, as noted earlier, explicit exploration of these memories is a separate task (and the focus of the following chapter). Unlike the memory work task, IC involves communicating to an imagined other the devastating impact of their treatment of the client and holding them accountable for harm. This has the goal not only of reprocessing specific disturbing events but also of healing attachment injuries (a process that may or may not involve reconciliation). IC also differs from more traditional exposure procedures in terms of the manner of implementation and the frequency of client participation in IC, which varies depending on individual client processes and treatment needs. The process itself is based on an empirically verified model that identified steps in the process of resolving past interpersonal issues (unfinished business), particularly with attachment figures (Greenberg & Foerster, 1996; Greenberg & Malcolm, 2002). This model provides guidelines for directing the process of resolving interpersonal trauma in EFTT. Again, it is important to appreciate how IC is distinct from other approaches to trauma exposure by virtue of its emphasis on interpersonal processes, whereby the client (in the role of victim) imaginarily interacts with a specific perpetrator of abuse and neglect. When the perpetrator is an attachment figure, this enacted interaction can be thought of as a behavioral or observable index of internal object relations or representation of the other.

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Object relations can be understood as the interpersonal component of an emotion scheme (see Chapter 3), activated, in this instance, by imagining the other. Emotional engagement with trauma material during IC is consequently more complex than simply fear expression while reliving a traumatic event. It also follows that trauma recovery in EFTT is more than simple desensitization to trauma material and the subsequent reduction of distress. As a meta-analysis has now shown, across therapy orientations and diagnoses (including working with trauma), emotional expression is a client process that has a medium to large effect on the prediction of good treatment outcomes (Peluso & Freund, 2018). And while the IC intervention begins with an exposure-like activation of emotion, it also fosters the subsequent elaboration and expression of emotions, something not typically part of exposure-based interventions. So, beyond desensitization to trauma cues, the building of resilience in EFTT involves the active creation of a new emotional repertoire for responding to old concerns (Pascual-Leone & Kramer, 2019). Recovery in EFTT primarily involves restructuring internalized object relations and constructing new and more adaptive meaning vis-à-vis both oneself and offending others. Moment-by-moment experiential shifts during IC gradually contribute to developing adaptive relational changes of this kind. These changes include not only the attenuation of negative feelings (hurt, anger, fear, shame) concerning the other but also reduced self-blame, increased self-empowerment, separation from the other, letting go of the rigid hope that a specific other will meet one’s needs, and more adaptive perceptions of abusive others as life-sized and human. Working With Current Interpersonal Problems Versus Past Trauma We provide a brief note here to distinguish IC for trauma or past unfinished business from “current interpersonal problems.” Both are “self–other” conflicts based on a similar model of resolution, with the goal of heightening awareness of feelings and associated wants and needs in a relationship (e.g., boundaries, respect) and thereby constructing more adaptive perceptions of self and other. However, resolving current relational issues focuses on how best to get needs met in the current relationship, what the client is willing to settle for, and what their “line-in-the-sand” is (i.e., what they insist on, refuse, or are unwilling to accept) in terms of the relationship moving forward. For example, a turning point for one client was realizing he was not willing to do anything to save the relationship with his father. In short, current interpersonal problems are about negotiating the challenges of relationships in the present. These can be addressed through imaginarily interacting with the current other but also through working on interpersonal skills such as assertion. In contrast, during IC, the client interacts with the imagined other from the past and focuses on past injuries and the cumulative effects of early traumatic experiences. Of course, clients may be suffering both current interpersonal problems and past relational trauma with the same person at the same time. For example, a client may have endured chronic abuse by a parent in childhood but then

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interact with that parent or even be stuck caring for the aging parent later in life. Although both past and present interpersonal problems can be a focus of EFTT, it is important to keep these two kinds of concerns separate, where negotiating today’s challenges is different from ICs with specters of the past. When the client is imagining and dealing with past issues in IC, again, it is important to clarify that it is the perpetrator from the past they are confronting, not the current other—a parent who may be old and frail, for example. The client expresses anger and sadness from their current adult perspective (e.g., “What would you have wanted to say or do if you could?”) because, as a child, they could not express these things. Importance of the Initial Dialogue The goal of the IC procedure at this early phase of therapy is to begin the process of exploring issues with the client’s perpetrators in-depth. This intervention quickly activates core emotional processes and clients’ processing difficulties for their subsequent exploration and change. The latter are the sticking points for therapeutic work, as identified in earlier sessions. In this way, observing client engagement in the initial IC procedure helps with consolidating preliminary case conceptualization. Moment-by-moment observations of how a client experiences, regulates, and works with such emotionally evocative situations contribute to understanding the generating conditions of a client’s disturbance and usher in a discussion on the goals and tasks that will be a focus for the rest of treatment. Research across different approaches has long supported the importance of high-quality client processes and a good start early in therapy (e.g., Horvath & Symonds, 1991; Jaycox et al., 1998; O’Malley et al., 1983). Productive engagement with past traumatic experiences in early sessions helps set the course for the remainder of therapy, allowing maximum time for exploring and reprocessing. From a learning perspective, clients’ initial experiences of confronting imagined perpetrators and accessing painful material should be successful and reinforcing. Later sections of this chapter elaborate on how to help bring this about. Because painful emotion is inherently aversive and has been staved off by many clients, the value of emotional engagement in IC is not always self-evident to them. In these instances, introducing the initial IC should be accompanied by connecting it to the collaborative case formulation and supported by psychoeducation about working with emotion. Original research on the effective use of EFTT indicated that the quality of clients’ engagement during IC remained relatively stable from the initial to later sessions (Paivio et al., 2001, 2004). Research also indicated that the first IC intervention can have a lasting positive influence on client change. In one study (Holowaty & Paivio, 2012), most clients who were interviewed at the end of therapy identified the initial IC as one of the most helpful events in therapy. Clients stated that what was particularly helpful was realizing, for the first time and at a gut level, the impact that early experiences of abuse and neglect had on them. It is likely that the novelty of the IC procedure played a role in the salience of these initial episodes. As noted earlier, a successful

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experience of confronting trauma feelings and memories in the presence of a supporting therapist also contributes to strengthening the therapeutic alliance— a finding that has important implications, especially for clients who have suffered relational trauma. Another foundational study further indicated a significant association between the initial engagement of clients during IC and the resolution of their abuse issues at a 6-month follow-up (Paivio et al., 2001). This suggests that engagement in the first IC intervention may have a delayed impact on resolution that did not appear immediately following therapy. People continue to process these experiences after therapy has terminated. There is also an important clinical relationship between the quality of engagement in the initial IC and subsequent use of the intervention. Clients who were highly engaged in the first IC continued to be highly engaged in the procedure whenever it was used, and (unfortunately) clients who initially engaged at low levels similarly continued to engage only superficially. However, when it comes to participating in IC, the quality of engagement is independent of the frequency of participation. Thus, because dosage (quality × frequency) was the most predictive variable in terms of outcome, rather than quality or frequency alone (Paivio et al., 2001), clients who are only minimally engaged during the initial IC may need to be encouraged to participate in it more frequently to receive maximum benefit. Therefore, therapist observations of a client’s processes during the first IC will have implications for the treatment plan of that client. In short, therapists should not refrain from repeatedly using the IC procedure with clients whose quality of engagement is moderate or low in the initial session. Later in the chapter, we present strategies for dealing with client engagement difficulties.

INTERVENTION PRINCIPLES The following subsections elaborate intervention principles that are particularly important to enhancing the quality of client engagement in the IC procedure. Promote Ownership of Experience This principle of promoting ownership of experience involves shifting from a stance of victimization, reducing client minimization and invalidation of their experience, to a stance of client assertive communication. This is accomplished in part by directing and redirecting client attention to their internal experience and modeling or encouraging the use of “I” language rather than focusing on events or the other’s behavior or hurling insults at the other. Promoting such ownership is illustrated in the following example: CLIENT:

He’s such a disgusting pig!

THERAPIST:

Yes, I hear how angry you are. Tell him what makes you so angry.

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Or in another example: CLIENT:

I don’t like to be angry at her; she had a hard life.

THERAPIST:

I hear that you don’t want to blame, but it’s important not to discount your own feelings either. Try saying that to her: “I don’t want to blame you but . . .”

Essentially, interventions like these promote a client’s depth of experiencing, the goal of which is self-exploration that becomes increasingly personal and affective in quality.

Evoke Memories Memories of abuse and neglect either spontaneously emerge in the process of imagining a confrontation with offenders or will be deliberately elicited by the therapist. A client’s memories of concrete and specific events (e.g., “I remember the terror of hearing my parents fighting outside on the driveway”) are more likely to activate core emotion and meaning structures than vague or generic memories (e.g., “I remember they used to fight all the time”). So, therapists aim to facilitate the former rather than the latter. Evocative empathic responses that are personal, concrete, and specific and that include the use of connotative or metaphoric language help activate this core material. For example, the therapist might say, “That must have been so frightening for you as a little girl, alone in your room, hearing them fighting, imagining . . . what? . . . they were going to kill each other?” The client can be encouraged to express to the imagined other what it was like for them to “get them to understand.”

Balance Attending to and the Expression of Internal Experience Subjective internal experience is the primary source of new information in EFTT, and so, as we have seen, one overarching treatment objective is to help clients articulate their subjective reality (promote experiencing). Thus, the therapist’s interventions must balance directing attention to internal experience (e.g., “Sounds like you feel pretty resentful remembering what he did; stay with that”) with directing expression (e.g., “Now, tell him what makes you so resentful, what a good father should have done”). In this effort, clients are regularly asked to (a) check how they are feeling “on the inside,” (b) deliberately put words to that experience, and (c) direct expression to the imagined other. The general rule here is to first explicitly direct clients to attend inward and then express that internal experience. The initial IC can be powerfully evocative of core emotional processes, including processing difficulties observed in earlier sessions, making them available for exploration. The following are some additional general emotion-

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focused therapy intervention principles most relevant to implementing the initial IC procedure. • Promote suitable emotion regulation: Reduce excessive (disorganizing) arousal through empathic affirmation and attention to breathing and using a presentcentered focus and/or increase arousal to productive levels through evocative empathy. • Help clients symbolize the meaning of their experience, including unmet needs and the effects of childhood maltreatment on self and relationships. • Communicate observations about the client’s process as an aid to task collaboration (e.g., “I see that really touches you. Can you put words to those tears?” “You say the words, but somehow, it’s hard to get in touch with those feelings.”).

THE PROCESS OF ENGAGEMENT IN IC The following sections present an overview of the model of resolution shown in Figure  6.1, with an emphasis on the initial dialogue. Next, the Levels of Engagement Scale (Paivio et al., 2001) is presented to help describe the features of high-quality engagement in IC. Finally, we focus on therapist interventions that promote client resolution at each step in the process. Steps in the Process of Resolution The IC intervention in EFTT is guided by the model of resolution presented in Figure 6.1. Modifications to the original general model and the specifics of this task (Greenberg et al., 1993) include a central focus on separate tasks of resolving trauma memories and self-related disturbances (bottom of Figure 6.1). Thus, in the process of resolving relational trauma, specific memories of maltreatment are explicitly evoked and explored. Furthermore, in the early stages of therapy with clients in this population, full emotional expression is typically blocked by secondary self-related disturbances (i.e., fear, avoidance, shame, self-blame). These difficulties are observed in the first IC, and they prevent the client from moving forward in resolving issues with abusive and neglectful others. These become separate tasks in the middle phase of therapy. The IC procedure shown in Figure 6.1 requires following and directing client processes (experience and expression) and the interaction between the self and the imagined other (top of Figure 6.1) enacted in different chairs. In the early stage, the client feels victimized, and the other is viewed negatively as the internalized “bad object.” Even when the imagined other is not enacted by the client, it is critical to track the client’s evolving perceptions of the other throughout the process and over the course of therapy. Similarly, even when the IC technique is not explicitly used (this is described later in the chapter), steps in the model guide the process of intervention and resolution (Paivio et al., 2010).

FIGURE 6.1.  Model of Resolving Interpersonal Trauma Using Imaginary Confrontation or Evocative Exploration PHASE 1

PHASE 2 PHASE 3

Evoked sense of negative other

Specific negative aspects of other

More differentiated view of other

Marker Global distress, hurt, blame, complaint concerning other

Resolution

Maladaptive fear, avoidance, shame, loneliness

Work with episodic memories involving fear, shame, loneliness

Work with self–self conflict • Catastrophizing • Self-criticism • Self-interruption

Uninhibited adaptive anger and sadness

Unmet need

Deserving of unmet need

Note. Adapted from Facilitating Emotional Change: The Moment-by-Moment Process (p. 248), by L. S. Greenberg, L. N. Rice, and R. K. Elliott, 1993, Guilford Press. Copyright 1993 by Guilford Press. Adapted with permission.

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Differentiated feelings regarding other (fear, shame, anger, sadness)

Self-affirmation and empowerment Letting go of expectations regarding other Holding other accountable for harm Optional: Forgiving other

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Early research by Greenberg and Foerster (1996) and Greenberg and Malcolm (2002) identified process steps in the original theoretical model that discriminated clients who resolved issues from those who did not. These core components resemble those related to the process of resolving global distress that was discussed in Chapter 3 on emotion and presented in Figure 3.1 (PascualLeone & Greenberg, 2007). The core components of resolution during IC are as follows: • • • •

identification of negative perceptions of the imagined other, intense expression of adaptive emotion (i.e., assertive anger, grief-sadness), expression of needs and entitlement to unmet needs, and changed perceptions of the self and significant other.

Accordingly, clients who resolved issues shifted to a stance of increased self-affiliation, self-empowerment, and separation from the other. They also developed a more differentiated perspective of the other and held the other (rather than themselves) accountable for harm. In some cases, for example, when the imagined other is perceived as a remorseful attachment figure, resolution may include forgiveness. In other cases, where the imagined other is perceived as cruel or abusive, resolution most frequently involves seeing the other as less powerful and perhaps “sick” or pathetic. In either case, full resolution of the trauma always includes appropriately holding perpetrators of harm accountable for the injuries they have inflicted. The Degree of Resolution Scale An abbreviated version of the Degree of Resolution Scale (Greenberg & Hirscheimer, 1994) is presented in Appendix C. This scale was developed to assess the degree to which clients have resolved issues with specific offenders who are the focus of therapy, according to steps specified in the original resolution model (Greenberg & Foerster, 1996). Although the measure describes hierarchically organized levels of process, working through relational trauma is not a linear process. The client may reach a specific level of resolution during a particular session (e.g., entitlement to unmet needs) but slide back to an earlier level (e.g., self-doubt and self-blame) in the next session. Even within the same session, clients can cycle through the levels, gradually moving closer to full resolution. Moreover, this “two-steps-forward-one-step-backward” progression has been empirically demonstrated to be part and parcel of emotional processing within productive therapy sessions but also over the course of an entire treatment (Pascual-Leone & Kramer, 2019). The final resolution (i.e., good outcome) of complex trauma is not always as self-evident as it may be with symptom reduction in uncomplicated depression or social anxiety. The Degree of Resolution Scale is useful in conceptually formulating the kind of good outcome or changes clients are working toward. On the one hand, the measure helps anticipate the tasks and goals of treatment and, as such, it informs case formulation. On the other hand, the measure is also a useful clinical tool for tracking clients’ progress through the resolution

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process. It can be helpful for therapists, at the end of each session, to note the degree achieved by the client in the session and use this as a guide for the following session. For example, during one session, a client acknowledged her unmet need for her mother’s affection—“I wanted to be the apple of her eye”— but did not feel fully entitled to having that need met: “I sound like a spoiled brat!” This indicated a need for the therapist to focus on enhancing entitlement in subsequent sessions. Levels of Engagement At any point during the IC procedure, the quality of client engagement with trauma material is important, irrespective of the stage they may be at in the resolution process. All therapy approaches recognize the importance of highquality client processes during key interventions. How do we know when the client is productively engaged in IC, and what should we observe? Answering this question will inform clinicians about what they are trying to promote in the intervention to enhance good process and maximum change. Clinical observation has indicated considerable variability in the quality of client engagement during IC such that interaction with an imagined other can range from being completely absent to a few tentative utterances interspersed throughout the session to continuous and intense involvement that sometimes lasts for the entire session. Early research that formed the groundwork for the development of EFTT behaviorally defined optimal quality of client engagement in IC to measure its variability over the course of treatment. The Levels of Engagement measure was then used to examine how these criteria predicted better outcomes (Paivio et  al., 2001). Defining what constitutes high-quality engagement has important implications for effective intervention. A key issue is that these aspects of engagement are directly observable to therapists. This is different from monitoring engagement by asking clients to rate their covert experience in terms of subjective units of distress (SUDS), as done in classic exposure-based interventions. The fact that markers of good engagement in IC should be observable emotional expression is consistent with the meta-analytic finding that observer-based measures of client emotional expression are significantly stronger predictors of outcome than a client’s subjective ratings (e.g., SUDS; Peluso & Freund, 2018). Engagement quality, therefore, is defined in terms of process elements that are generally important in expressive and experiential therapies and of special importance to therapy for trauma, as well as those features that are unique to this specific intervention. In the end, the quality of engagement is described in terms of three dimensions: (a) maintaining psychological contact with an imagined other in an empty chair, (b) involvement in the therapy process, and (c) expression and exploration of affective experience. We developed the Levels of Engagement Scale (Paivio et al., 2001) to assess client processes during IC on the basis of these process dimensions. Observable dimensions of this scale are described next and can be used by the therapist to assess the quality of client engagement in the IC procedure.

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First, criteria that define the dimension of psychological contact include descriptions of the imagined other, looking at the imagined other rather than the therapist, and the use of first- and second-person pronouns (I, you) rather than third-person pronouns (he, she) while in dialogue with the imagined other. In brief, the client behaves as if the other were in the room rather than reporting on events. Second, the dimension of involvement is closely related to the construct of client experiencing described in the preceding chapter. Criteria include willing participation in the intervention rather than resistance (e.g., refusal to speak to the imagined other), expressiveness rather than withdrawal, and spontaneous elaboration and initiating dialogue with the imagined other rather than simply complying with therapist directives. Third, criteria for emotional expressiveness include the client admitting feelings (e.g., “I feel so angry when I remember what he did to our family”) and nonverbal indicators of arousal (e.g., vocal quality, facial expression, tears). Research ratings on the Levels of Engagement Scale were based on the observation of videotaped therapy sessions, where high ratings indicate emotional engagement with trauma material during IC for an extended length of time. As expected, results indicated variability in client engagement quality during the first IC (Paivio et al., 2001). Most clients required considerable support and coaching from their therapist to confront imagined perpetrators for the first time. Furthermore, as we have discussed, for most clients, the quality of engagement during the initial IC sets a precedent for the rest of treatment; this underscores the importance of promoting the best processes possible as soon as possible. Factors Related to Client Engagement in IC The research on client engagement (Paivio et  al., 2001, 2004) indicates that about one quarter of EFTT sessions contains substantial work using the IC procedure. To understand the client characteristics related to participation and thereby explore the applicability of the procedure, the studies examined the relationship between engagement quality and several client variables. These included gender, type and severity of abuse, severity of current trauma symptoms, social anxiety, and the presence of a personality disorder. Prior research and clinical observation had already indicated a link between some of these factors and participation in other exposure-based procedures. For example, severe problems with emotion dysregulation (i.e., current trauma symptoms) have been associated with difficulties confronting trauma memories, which is why many effective treatments include a client stabilization phase at the beginning of therapy (see Ford & Courtois, 2020). Results of investigations of EFTT, however, have shown no systematic link between the severity of trauma symptoms and engagement in IC. An important caveat here is that clients in EFTT clinical trials were screened for suitability for a short-term trauma-focused

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therapy that would preclude severe problems with emotion dysregulation. In standard clinical settings, however, many clients do experience severe dysregulation that must be addressed before they are ready for trauma work. That said, client engagement in IC also is likely because therapists in EFTT collaborate with their clients on when, how, and how often they feel able to confront trauma material. Moreover, during the IC procedure, therapists provide empathy, support, and guidance in response to individual client needs. To date, the only client characteristic studied that has interfered significantly with engagement in IC is the presence of personality pathology (Paivio et al., 2004). About one third of clients in EFTT clinical trials have met the criteria for some form of personality disorder, the most frequent being avoidant, narcissistic, and borderline personality disorders. These disturbances are characterized by long-standing self, interpersonal, and emotion regulation difficulties that typically require a longer course of therapy. Overall, clients with personality problems may find it challenging to keep a sustained focus on disclosure and exploration of emotional processes in IC and EFTT. Importantly, however, adaptations to chair work with personality disorders have been developed, although containment and coherence tend to be the intervention focus over resolving trauma, per se (see Pos & Paolone, 2019). The IC procedure requires clients to express thoughts and feelings to an imagined other in the presence of the therapist. Clinical observation has suggested that severe client social or performance anxiety can interfere with engagement in enactments such as IC. At least one early study of emotionfocused therapy with a general clinical sample found that client nonassertiveness and social anxiety prognosticated poorer outcomes (Paivio & Bahr, 1998). Considering the prevalence of shame, distrust, and fear of negative evaluation among survivors of child abuse, it is not surprising that, in some instances, a client’s nonassertiveness and social anxiety interfere with adequate engagement in IC. In the end, proposing and getting an agreement from the client to do chair work is a process of negotiation as therapists contextualize the task in terms of a case formulation, and clients get a progressively clearer sense of what they are agreeing to. Research has started to examine the conversational turns that lead to clients’ enthusiastic engagement in chair work such as IC (Muntigl et al., 2020). However, observation also consistently suggests that one of the best predictors of whether a client will engage in these enactments is simply the confidence with which they are introduced by the clinician. Therapists, therefore, must provide unambiguous instructions and ensure that a client’s performance anxiety is not a function of the therapist’s lack of confidence or skill. Overall, IC is designed to be flexibly implemented to accommodate individual client differences in interpersonal and processing style and treatment needs. The procedure, therefore, is broadly applicable to men and women dealing with different types of abuse and with a range of trauma and trauma symptom severity.

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STEPS IN THE IC PROCEDURE AND CORRESPONDING THERAPIST OPERATIONS While Figure 6.1 describes the client processes that lead to resolution, the following sections summarize the therapist operations that facilitate the IC procedure. Therapist operations are intended to facilitate client movement through the increasing degrees of resolution presented in Appendix C. In terms of the initial IC, the primary goals are to elicit a client’s negative perceptions of the imagined other and then help the client begin to differentiate global distress and bad feelings into separate emotions (anger, sadness, fear, shame) and their associated meanings. Using IC in the Early Phase of EFTT The following subsections specify therapist operations that facilitate client process steps in each stage during Phase 1 of EFTT. Predialogue Stage The first predialogue stage of the IC procedure involves (a) collaborating on the task and (b) initiating and structuring the intervention. Collaborating on the task and using the IC procedure.  Issues to be considered before the initial introduction of IC concern the choice of imagined other and development of a rationale tailored to the individual client. The decision regarding who will be the focus of the first IC (i.e., the imagined other) can be based on in-session client markers (e.g., reports of nightmares or troubling encounters with perpetrators) or client preference or chosen by the therapist based on information about the client. Sometimes it may be more effective to engage a less-threatening other—for example, a parent who minimized abuse—rather than imagining a malevolent other with accompanying memories of severe violence and horror. The overarching goal in the initial dialogue is to ensure a successful experience in engaging and processing trauma material at a deeper level than in previous sessions, without the client being overwhelmed. Therapists also should prepare for the first IC by developing a rationale tailored to their client, anticipate how the client will respond to the procedure, and consider, on the basis of earlier sessions, problems that could emerge and how to address them. Of course, this planning in advance needs to be balanced with responding to the moment-by-moment client processes in a session. Before introducing the IC procedure in Session 4, the therapist and client need to agree on the task of in-depth exploration of painful or threatening issues with a specific other person who has been the focus of therapy. The therapist asks the client what feelings and memories come up when the therapist suggests this focus. Whether the choice of imagined other is pre­ determined or emerges spontaneously, the therapist needs to elicit and/or

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confirm appropriate markers for beginning IC (e.g., “It sounds like you are still very upset when you remember what he did?”), to which the client agrees. Initiating and structuring the IC procedure.  In this step, the therapist suggests a dialogue with an imagined other as a means for deepening the process (not speaking about feelings but from feelings) and provides the brief rationale (e.g., “You were always shut down. Here is a chance to say what you really felt and get it out in the open so we can look at it, so you can get some clarity. I’ll help”). After clients agree to participate in the task, the therapist places an empty chair in front of them and provides clear instructions for participation—for example, “Pay attention to what is going on inside—your thoughts and feelings—as you imagine your father over there, and put words to those. Speak from your heart and gut.” Client resistance, reluctance, or difficulties are validated and, if possible, either bypassed or quickly addressed. Dealing with difficulties that cannot be bypassed (e.g., severe avoidance or dysregulation) is the focus of the middle phase of therapy, presented in later chapters. When initially confronting the imagined other, depth of experiencing may be low (i.e., a focus on external events and the others’ behavior), and the client may express blame and complaint concerning the other and undifferentiated distress. An important intervention principle in moving the client forward is to promote ownership of experience so that exploration becomes increasingly personal and affective in quality. When clients are resistant because they feel it is pointless to do a “pretend” dialogue because the other will never change or “you can’t change the past,” interventions should validate these perceptions and explain that this repeated squashing down of their feelings is what has kept them stuck. Furthermore, the purpose of the intervention is not to change the other (or the past) but to understand and strengthen the authentic self, which will help the client come to terms with the past. Arousal Stage The arousal stage of the IC procedure involves (a) evoking an emotional reaction, (b) differentiating feelings toward the other, and (c) facilitating enactment or a vivid experiential memory of the imagined other. Evoke emotional reaction in response to the imagined negative other. It is important to understand that, at this stage in the procedure, the imagined other primarily serves as a stimulus to evoke an emotional response in the self—that is, to activate the maladaptive emotion scheme or pattern of thoughts, feelings, and behaviors regarding the other. This is accomplished by evoking the sensed presence of the imagined other in the empty chair—their facial expression, posture, or tone of voice. Importantly, the client is asked to provide only as much descriptive detail as is necessary to evoke a response. Interventions need to highlight the essential quality of the imagined other (e.g., “Back turned to you, it’s like he’s shutting you out,” “That tone of voice— what’s the message being sent?”). Episodic memories involving the other can

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spontaneously emerge, clients can be asked to recall a specific event, or the therapist can suggest an event based on information gathered in earlier sessions. Eliciting concrete, sensorial detail of the event will help evoke the emotion scheme. Once the presence of the other is clearly evoked, interventions direct clients’ attention to their internal experience in reaction to the other (e.g., “What comes up for you on the inside when you imagine him there, with that look on his face?”). This is followed by encouragement to express clients’ reactions to the other. An important principle in directing the dialogue throughout is to balance directing client expression with directing client attention to internal experience. During the early phase of therapy, the client typically responds to the imagined other from a stance of powerlessness and victimization and may collapse into hopelessness or resignation. Interventions in response to these markers (e.g., when the client says, “What’s the point? Nothing will change no matter what I say”) should again highlight the purpose of the intervention. Other common client responses include extreme distress in response to memories of sexual abuse, violence, and horror. For the client Monica, for example, the initial IC activated panic and difficulties breathing as she recalled finding her mother after her mother had shot herself. Another client collapsed into tears recalling her father beating her younger brother. In these instances, therapist interventions affirm client vulnerability, promote emotion regulation, and momentarily deflect from IC to address the immediate difficulty and affirm the safe context of the therapeutic relationship. For Monica, this involved helping her block out visual images of her mother so she could reengage in IC. For the client who recalled her violent father, this involved expressing her feelings to the therapist rather than her imagined father. The evocative exploration procedure, described in a later section, was designed for clients who are decidedly unwilling or unable to express feelings and needs to imagined perpetrators. Clients can move back and forth between IC and evocative exploration as required. It is most helpful for clients to express anger experiences directly toward abusive others because this facilitates self-empowerment. In contrast, more vulnerable feelings such as fear, shame, or sadness require support, so these are expressed either to the therapist or toward an imagined other who is perceived as potentially responsive to the client’s suffering. Client responses during the first IC are also frequently focused on external circumstances and the behavior of the other. This can involve a client intellectualizing, minimizing harm, and making excuses for the abusive other (e.g., “I know she had a difficult childhood”). Again, interventions to deepen experiencing validate the client’s perspective and redirect their attention to their affective experience (e.g., “What do you feel in your heart, gut, or body when you remember or imagine . . .,” “You are good at understanding her perspective, but you don’t want this to be at your own expense”). At the other end of the spectrum, clients get distressed and may shut down (e.g., dissociation). This could be so severe that they are unable to continue in a

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dialogue with the imagined other. Alternatively, some clients want to maintain contact with the therapist rather than an imagined other (e.g., the client says, “I would rather talk to you”), or they resist engaging in the IC procedure for other reasons. These difficulties need to be explored and addressed. Sometimes trauma exploration can be discontinued altogether until other issues are resolved. In-depth exploration of persistent self-related difficulties will affect trauma exploration or IC participation and are the focus of later sessions during Phase 2 of EFTT. Differentiate feelings toward the imagined other.  The immediate process goal at this stage of the IC process is to help differentiate client global upset, distress, or blame into clear expressions of primary emotions to access the unique information associated with each (see Figure 3.1 in Chapter 3). The goal is to help the client move toward the assertive expression of healthy anger and sadness. Clients typically shift between anger and sadness, and interventions must validate both experiences as legitimate and important and encourage the client to focus on each, one at a time. The decision about which emotion to highlight can be based on the presence of predominant markers for each emotion. Anger, for example, is associated with references to injustice and unfairness, whereas sadness is associated with deprivation, separation, and loss. This decision is also based on the therapist’s understanding of the case. For example, in helping clients grieve losses, the therapist preferentially reflects sadness (what was missed or missed out on) when both anger and sadness were present. Alternatively, the client can be asked which emotion they are most in touch with in the moment. For example, in the initial IC, Monica angrily responded to the imagined mother’s excuses by saying, “I don’t accept those excuses!” Therapist interventions specifically labeled anger and helped Monica symbolize its meaning (e.g., “So you don’t accept those excuses—tell her what you resent, the damaging effect that her suicide has had on you all these years”). In work with complex trauma survivors, adaptive anger and sadness frequently and repeatedly collapse into fear or shame and self-blame, and therapists need to identify these and work with them separately. A focus on modifying these maladaptive emotions takes place during later sessions in Phase 2 of therapy. Facilitate enactment (or vivid experiential memory) of the imagined other.  When therapists vivify the client’s experience of the other, the purpose is to intensify the stimulus function of the imagined other. Clients are asked to imagine how the other would respond to their expressions and might be asked to “switch chairs” and respond from the other chair. Markers for switching chairs are like normal conversational markers that call for a response from the other party (e.g., the client may say, “You should have . . .,” or “I want you to . . .”). During the initial IC, the client may or may not enact the imagined other. In our experience, clients will not want to enact (or identify with) an imagined other who is seen as frightening, disgusting, or despicable. At this early stage

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in the process, it does not matter whether the other is enacted or not. The therapist’s aim is to highlight, clarify, intensify, and perhaps exaggerate the core meaning of the other’s response to evoke a response in the self. For example, a client imitated the screechy voice of her mother calling her father’s name (“Frank!!”). The therapist echoed this vocal quality and asked the client to articulate the meaning (“Like a shrew . . . or a witch? How do you feel when you remember her voice?”). Again, it is critical to continually track client perceptions of the other during IC because these shift over the course of therapy as the client’s self-esteem and confidence increase. Using IC in Phase 2 of EFTT Clients with a history of developmental trauma have self-related difficulties (i.e., avoidance, self-interruption, guilt, self-blame) that interfere with engaging in IC and particularly with the uninhibited expression of anger and sadness (see the bottom of Figure 6.1). The emotional processing difficulties related to emotion awareness, regulation, reflection, and limited access to adaptive emotion and resources for emotional transformation that were identified in earlier sessions (see Chapter 4 on case conceptualization) are also observed during the first IC. In Phase 2 of EFTT, resolving those difficulties becomes the focus of therapy and separate tasks. Therapists provide process observations (e.g., “Even though you know you were just a child, somehow you still blame yourself”) and then a rationale for reducing these blocks that interfere with functioning and trauma resolution. The IC procedure is not entirely abandoned during this middle phase but instead is used in conjunction with other interventions for exploring and reducing these blocks. These are described in Chapters 8 and 9. Using IC in Phase 3 of EFTT Once self-related disturbances are gradually worked through, the client will be increasingly better able to confront the imagined other during IC. The following steps in the resolution model begin with a full experience and expression of anger and sadness, which are the catalysts for resolution. These steps are described briefly next to provide direction for later sessions, and they will be further elaborated on in Chapters 10 and 11. It is important to note that although the following steps are most typical of a later phase of therapy, they could occur at any time. No matter what phase of therapy the client is in or what degree of resolution the client has achieved, the goal is to help the client move, step by step, session by session, closer to full resolution and do so as quickly and efficiently as possible. Expression and Exploration Stage The expression and exploration stage is intended to facilitate higher levels of resolution (see Appendix C), which focus on the full expression of anger and sadness (and associated meanings) to the imagined other. Increased arousal is

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accomplished by encouraging the client to approach painful or threatening emotion, adopt a body posture and vocal quality consistent with the focal emotion, and use emotion intensification techniques (see the section on intervention principles in Chapter 2). Next, interventions facilitate the expression of and entitlement to unmet needs. Here, the client begins to define the self in terms of legitimate wants and needs (e.g., justice, attention, love). Arousal also decreases and experiencing increases as clients explore the effects of having had their needs neglected. Resolution Stage In the final stage, interventions support the emerging new understanding of self and other. The client is no longer seeking retribution or an apology (e.g., “It doesn’t matter anymore what he thinks; I know the truth”). Through enacting or imagining the other’s reactions to the client’s expressions, the client begins to see the other in a more differentiated fashion and, at the same time, begins to hold the other (rather than self) accountable for harm. Whatever degree of resolution the client has achieved during a specific therapy session, one can skip ahead to ending the IC task for the time being. This takes place by helping the client close contact with the other and process the experience to date, taking stock of where they are thus far in their work. This could include bridging to the next session (e.g., the therapist might say, “Okay, so you’re not done—tell him you’ll get back to him”), saying goodbye, or asserting expectations and boundaries in the current relationship (e.g., “Tell her you are only willing to see her when she’s sober”). Here, processing also entails setting goals for subsequent sessions, ensuring client safety and emotion regulation between sessions, and providing reassurance and hope for resolution (e.g., “I know it’s still not finished for you. We will continue to work on this. We have time.”). Over time, processing the IC experience involves integrating it with other therapy experiences and the client’s current life.

RELATIONSHIP DEVELOPMENT IN THE INITIAL IC Introduction of the IC procedure during Session 4 is a bridge between the first and second phases of therapy. IC introduces new elements into the relationship dynamic, and it is, therefore, essential to pay specific attention to features of the relationship during the first IC. The following sections describe the components of alliance development that were presented in the alliance chapter as they apply specifically to the IC procedure. These features remain important throughout the therapy process. Establish a Secure Attachment Bond Therapists ensure safety and support during IC by empathically responding to client processes, not just directing the process. This particularly includes providing empathic affirmation of client vulnerability and as much interaction

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with the therapist (as opposed to the imagined other) as is needed by the client. It is important to collaborate with clients about the procedure and to assure them that they ultimately have control over the process. The therapist’s role is to guide the process, provide support, ensure adequate time for processing the IC experience, monitor client composure, and ensure the client has adequate resources for coping after the session. Provide Emotion Coaching and Awareness Training Emotion coaching during IC involves explicit information and guidance about how to participate in the procedure and why. Intervention principles that increase client awareness of emotional experience during the initial IC include directing client attention to internal experience, promoting ownership of experience (e.g., assertive expression using “I” language), and helping clients accurately label their feelings and symbolize the meaning of their experiences. Ownership is accomplished through modeling and gradually shaping client behavior rather than explicit teaching or “correcting” their behavior. For example, when the client says to the imagined other, “You’re so selfish!” the therapist validates and empathically responds, “Yes, so very angry! Tell him more about how his selfishness has affected you.” Promote Emotion Regulation It is important to closely monitor client levels of distress during the IC procedure (e.g., the therapist asks, “What’s going on for you right now?”). Therapist soothing responses, attention to breathing, and present-centered focus can be used to reduce distress. More explicit emotion regulation strategies can be used when clients are feeling overwhelmed, intervention can switch to evocative exploration (EE; described in the next section) if confronting the perpetrator is the problem (e.g., too evocative or too noxious), or trauma exploration can be abandoned completely until the client has a greater capacity for emotion regulation. However, evocative empathic responses (e.g., “So, you feel discarded, like a piece of trash”) can increase the emotional intensity to work through instances of what was previously avoided. At this point, avoidance processes are observed and, if they persist, become targets for intervention in later sessions. Collaborative Case Conceptualization The evocative nature of IC quickly activates core processes, making them available for exploration and change. Thus, the intervention can serve as a performance-based assessment of problem points and the specific maladaptive processes that have interfered with trauma recovery. Emotional processing difficulties related to awareness, regulation, reflection, and transformation (i.e., limited access to adaptive resources) and task markers (e.g., self-interruption, self-criticism) that were identified in the first three sessions will typically emerge in the initial IC. The first IC, therefore, is an opportunity to refine the case

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conceptualization developed in the first three sessions. Interventions that aid in developing a collaborative understanding of these difficulties include directing client attention to internal experience and process observations that have an exploratory quality (e.g., “It’s like part of you is furious, and the other part somehow says it’s not valid to feel that way? Let’s spend some time looking at that”). This refined case conceptualization forms the basis of intervention in the middle phase of therapy.

EVOCATIVE EXPLORATION AS AN ALTERNATIVE TO IC Early research on EFTT (Paivio et al., 2001) indicated that a significant minority of clients (20%) refused to participate in IC over the course of therapy. Another subgroup (36%) was initially resistant to participating and experienced a variety of difficulties. This is consistent with research on other stressful exposurebased procedures (see Ford & Courtois, 2020) and was the impetus for developing the evocative exploration (EE) procedure, which serves as a less stressful alternative to IC. Importantly, the EE procedure is based on the identical model of resolution (see Figure 6.1) and incorporates the same intervention principles and the same criteria for engagement as IC, only without the physical use of an empty chair (Paivio et al., 2010). In EE, clients are encouraged to imagine perpetrators in their “mind’s eye” rather than in the empty chair, and feelings and memories concerning abusive and neglectful others are explored exclusively in inter­ action with the therapist (e.g., the therapist might say, “Tell me [versus her] more. Her minimization of your pain must have been so devastating”). Results of a clinical trial indicated comparable efficacy of EFTT with EE alone compared with EFTT with IC (Paivio et al., 2010). Clients in EE made large gains on multiple dimensions, which were maintained at 1-year follow-up. Research on the in-session processes also revealed that both IC and EE interventions were comparable in terms of levels of experiencing, quality of client engagement with trauma material, and levels of client-reported distress (measured on the Subjective Units of Distress Scale) that, as expected, diminished over the course of therapy (desensitization; Chagigiorgis, 2009; Ralston, 2006). Finally, observed levels of emotional arousal (whether productive or unproductive emotion) were lower during EE, and the dropout rate in EFTT with EE was 7% compared with 23% in the IC condition (Ralston, 2006). The 7% attrition rate in EFTT with EE is remarkable, given that rates reported for other exposure-based therapies (Goetter et al., 2015) are in the 20% to 30% range. Overall, the findings support EE as an effective and less stressful alternative to the IC procedure. However, several factors must be considered before a clinician chooses EE over IC. First, comparable efficacy for the two treatment approaches was likely due to a sustained focus on trauma work, comparable client and therapist expectancies regarding efficacy, and the same underlying model of resolution and specific steps guiding the process. However, the IC

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procedure includes greater structure through the use of an actual empty chair, which may have advantages for both clients and therapists in tracking perceptions of the imagined other. It is also intrinsically evocative and has greater novelty, which may make it more memorable (e.g., Holowaty & Paivio, 2012). In the end, IC is a more complex interactional process that involves imagining a perpetrator sitting across from the client and enacting the other (whether the client switches chairs to enact the other or not), which likely evokes more multimodal experiential memories. Intuitively, it is more evocative and power­ful to stand up to an abusive other imagined to be sitting in front of you than to talk about these feelings with a therapist. Overall, trauma work during EE may be less stressful, but it also is less evocative and less distinct from the rest of therapy. Effective intervention during EE, therefore, requires careful therapist attention to using evocative language, activating emotion memories, and deliberately tracking perceptions of self and other. For these reasons, and given the evidence presented earlier that the dosage of IC contributes to client change and because most clients (about two thirds) can engage in IC (Paivio et al., 2001), we advocate the use of IC unless clearly contraindicated. A common therapist error in early sessions is shifting to EE too quickly in response to client difficulties with IC. In terms of engagement level, described previously, most clients are “reluctant” to confront imagined abusive and neglectful others. Therapists, therefore, should have realistic expectations for client engagement in IC and help clients persist despite their initial reluctance. Furthermore, these client processes in early sessions do not preclude reintroducing IC in later sessions once the client is stronger. Clients thus can move back and forth between EE and IC, discussed in a later section. Whatever the case, the research on EE validates the flexibility with which the original (IC) intervention can be conducted, and therapists can confidently make use of the flexibility this affords. This has important implications for other methods of treatment delivery, such as teletherapy for clients who cannot otherwise access services and do not have space to do chair-work (Pugh et al., 2021). Guidelines for Conducting EE Markers for choosing EE are clients’ inability to manage distress, dissociation, or outright refusal to participate in IC. The therapist might decide in advance not to use IC because of the client’s history and the risk of retraumatization or the involvement of an extremely malevolent and violent other, or these difficulties may only be observed once IC is introduced. Another indicator for abandoning IC after it has been introduced is resistance to participation. This struggle defeats the purpose of the procedure, which is to help clients express previously inhibited feelings and meanings. In shifting from IC to EE, it is important to reassure the client that EE is equally effective, essentially to communicate that their choice to decline IC is not a problem: “There are many ways to go about therapy; just talk with me for now and never mind

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the chair.” This reinforces clients’ feelings of control over the process, avoids feelings of inadequacy, and ensures optimal client expectations for benefit. The introduction of both IC and EE around Session 4 marks the beginning of trauma work—an in-depth exploration of painful and threatening experiences with perpetrators of abuse and neglect. Whereas in IC, it is important to attend to relationship issues, EE can easily merge with the normal dialogic relationship processes that occurred in earlier sessions. Explicit trauma work in EE, therefore, should be explicitly distinguished from the early phase of narrative disclosure. Therapists need to decide when they are beginning the task and then become deliberately evocative—EE is essentially IC of perpetrators, only without the empty chair. Therefore, it is essential to first collaborate on the task. During Session 4, after ensuring the client has no other pressing issues, the therapist might say, “I am going to suggest that we spend this session focusing in-depth on those abuse experiences with your father.” Typically, just suggesting this focus will already evoke some trepidation. When and if that happens, it is important to quickly validate, empathically affirm client vulnerability, provide reassurance, and ensure collaborative agreement on the task. Once the client agrees to the trauma focus, the therapist clearly introduces the task and deliberately evokes an emotional reaction by directing the client to thoughts and memories of the perpetrator: “What comes to mind as you imagine him, in your mind’s eye? Any specific incident? What does he look like?” Just as in IC, it is important to elicit only enough external detail to evoke a reaction; too much focus on an external description of the imagined other will cool the process. Here, the therapist uses directives and evocative empathy to increase arousal and activate the core emotion scheme. Therapists ensure that all the features of the EE process are comparable to those in IC. The procedure follows the same stages outlined previously. Therapists also ensure all the criteria for high-quality engagement in the procedure. To ensure psychological contact with the imagined other, the therapist elicits vivid descriptions of the other and the use of “I” language, storytelling that is sensorially vivid and personal. Therapists also promote other dimensions of engagement—exploration (e.g., “Say more about the effect that had on you— what made you so angry?”) and emotional expressiveness and arousal. Research examined the in-session processes during IC and EE (observed level of engagement, observed emotional arousal, client-reported subject units of distress) that contributed to treatment outcome in each of the treatment conditions—EFTT with IC or with EE (Ralston, 2006). Results indicated that for IC, the best predictor was the overall quality of client engagement in the IC procedure, whereas, in the EE condition, the best predictor of good treatment outcome was higher client emotional arousal during the EE procedure. This suggests that in the less evocative EE procedure, therapists must explicitly work at increasing client arousal through evocative empathic responding or other intensification strategies. They cannot rely on the intrinsically evocative nature of the empty chair as a prop. For example, during EE, a client who had

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been sexually molested by a priest recalled walking home through back alleys after an incident of abuse for fear of seeing any of his friends. The therapist’s empathic response, “sneaking around like a little criminal,” evoked healthy protest: “And I did no wrong!” The therapist reinforced this client response by asking him to repeat the statement and check inside as he said it to deepen his experiential awareness of this adaptive resource. This served to counteract maladaptive self-blame. It also is important to follow the changing perceptions of the other, which are obvious if the client is enacting the other in an empty chair, but in EE, the therapist must explicitly ask, “How do you imagine he would respond if he could hear you and know how you felt?” Just as in IC, perceptions of the other will become increasingly differentiated as the client becomes more resilient over the course of therapy. The client in the example shifted from viewing the priest as a purely malevolent “devil” to a pathetic pedophile who deserved to be jailed for his crimes. Just as in IC, EE also evokes the maladaptive processes related to fear, avoidance, and shame identified in the early phase of therapy. The client who had been molested by the priest kept returning to “I can’t understand why I kept going back,” and “I have to stop blaming myself.” These are markers of self-blame that the therapist identifies and, in the spirit of case collaboration, reassures the client that reducing self-blame will become a focus for the next phase of therapy. Switching Between IC and EE As noted earlier, initial engagement in EE does not preclude reintroducing IC later in the session or later in therapy when the client feels stronger or the other has softened or with the engagement of a less-threatening perpetrator (e.g., a neglectful mother compared with a brutal father). IC can also be briefly reintroduced at markers of client assertiveness during EE. This can be as little as a single statement directed at the imagined other and then checking the client’s experience of this assertive expression. In these instances, the less stressful EE can be thought of as part of gradual exposure, with the goal of full confrontation in IC later in the process. A case example of switching between IC and EE occurred with a client who was initially confronting her violent father during IC. This evoked a memory of him brutally beating her younger brother—“He was going to kill him”—and high levels of distress, sobbing, grabbing her throat, and being unable to continue: “I can’t do this; I can’t even look at him.” In this early phase of treatment, the therapist’s priority was to help the client tell the story and express her feelings rather than engage in any specific technique. The therapist empathically affirmed the client’s distress and encouraged her continued processing: “Never mind him [pushing the chair away]. Tell me, tell me what it was like. It’s okay; let it come.” The client, sobbing, described in detail the brutal beating, the father telling her he was doing this for the brother’s own good, and she protested, “He was like a crazy man, going at him like a

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machine, like he wasn’t even a human being. How could he do that?” At this marker of healthy assertive protest, the following exchange occurred: THERAPIST: Such a brute. . . . And if it had been possible, what would you

like to have said to your father? Just for a minute, can you look at him over here? [gesturing back to empty chair] Tell him. CLIENT: STOP! THERAPIST:

Yes, STOP. If you can’t be a proper father . . .

CLIENT:

Yes, if you can’t be a proper father, go away, leave us alone!

They then returned to processing in EE, in interaction with the therapist: CLIENT:

But he would never listen. . . . I’m mad at my mother too; she never protected us, she never protected herself either. He beat her too.

Later in therapy, the client was able to confront both her mother and father in the IC procedure.

CLIENT DIFFICULTIES WITH THE INITIAL IC Addressing client difficulties with IC requires collaboratively determining the nature of the difficulty, providing a rationale that makes sense to a client and increases their motivation to participate. Responding to markers of core “hot” internal processes always makes intervention using the IC procedure easier. Structure Is Not Conducive to Dialogue With an Imagined Other Structural problems in the predialogue phase (see the previous paragraph on steps in the IC procedure) concern the set-up of the chairs and instructions on how to participate in the IC procedure. Problems in these areas are the easiest to address. If a therapist avoids being in the client’s line of vision with the empty chair and is verbally less active, it is easier for a client to engage with an imagined other. The client faces the empty chair, and the therapist acts like a coach directing the process from the sidelines and providing only as much contact with the client as needed. If this structure is in place and the client continues to speak primarily to the therapist, the therapist should encourage the client to speak directly to the imagined other using “I–you” language and provide a brief rationale (e.g., “That’s important what you’re saying. I want you to try saying that directly to your father over there; it’s him you’re angry at”). Once the client complies with this, the therapist provides encouragement and directs the client’s attention to their internal experience (e.g., “Good—what was it like saying that to him?”). Here, one wants the client to be aware of the experiential impact of making psychological contact with the imagined other and understand that pressing through the difficulty has value.

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In instances when the client has difficulty imagining the other, it can be helpful to evoke an episodic memory of an interaction with the other: “Do you remember a time when . . .” Interventions help the client recall concrete, sensorial details of the event, which helps them to remember gestures, a tone of voice, a facial expression, or the size or smell of the other. The Client Is Unclear About the Task Typical areas of client confusion are whether to focus on the imagined other from the past or present and whether one would say or do this in real life. Lack of clarity can be due to an absence of appropriate markers for the IC intervention (i.e., the client does not express unresolved bad feelings concerning the other in the moment—see Figure 6.1) so that it does not make sense. If these markers have not emerged spontaneously, interventions must elicit them (e.g., “So, where are you at with your father?”). Again, therapists should keep their instructions short and simple (e.g., “Imagine your father in that chair—your young father, the one who beat you, not father as he is today. What do you see or sense?”). Clients also need to clearly grasp that the purpose of the intervention is not a rehearsal for real life, to effect change in the other, or change the past but rather to achieve clarity and resolution for themselves. The therapist might say, for example, “This is for you so you get clear—no censoring. Get rid of all that emotional baggage,” or “What you do in real life, later, is a different matter, and I can help with that too.” The Client Experiences Performance Anxiety When clients express feeling foolish or embarrassed, interventions should validate their concern but, if possible, bypass the difficulty. For example, the therapist might say, “Yes, it’s a little strange at first, but most people get used to it. Let’s give it a try because we know it can be really helpful. But if it’s not for you, don’t worry. We’ll find some other way of working.” As noted earlier, unless the client refuses to participate, do not abandon IC during a session; rather, move back and forth between IC and EE and briefly reintroduce IC (possibly without disruptively physically moving the empty chair) at markers of client expression of feelings, beliefs, or desires concerning the other. Client Need for Interaction With the Therapist When, despite directives to interact with the imagined other, clients say or imply (e.g., through eye contact) that they would rather talk to the therapist, the therapist should respond positively to this preference. At the same time, therapists may solicit clients’ permission to periodically, at critical moments, direct their expression to the imagined other (e.g., “Standing up to her, even in imagination, even for a couple of seconds, will help you be more assertive in ways that talking to me will not”). Again, after clients express their thoughts and feelings to the imagined other, interventions should direct their attention to their internal

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experience of doing this. This accesses information about the degree of resolution (e.g., the client might say, “It felt good,” or “It’s hard to believe my own words”) for subsequent processing. The Client Has Difficulty Enacting the Other A critical part of the IC process is to access client perceptions of the other. These perceptions are evident in the imagined response of the other to client expressions. Assuming clear instructions have been provided, clients’ difficulty enacting the other can be due to difficulties imagining the other or an aversion to taking on the role of the other. The therapist’s interventions support clients who do not want to enact the other (e.g., “That’s okay; never mind. How do you imagine he would respond or react to what you just said?”). The point here is to elicit a client’s perceptions of the other’s character, not just of the overt behaviors. Effective interventions highlight the essential quality of the other to evoke a response in the self. In addition to the technical difficulties, many clients’ emotional processing difficulties also are observed in the initial IC. Addressing those difficulties takes place in the middle phase of EFTT, the focus of the following chapters.

7 Memory Work in EFTT

T

he topic of memory work is central to trauma therapies across orientations. Memory work is not only central to recovery from traumatic fear but is also an alternative to two-chair self-critical dialogues (typical of emotionfocused therapy approaches) for reducing core attachment-based shame. The preceding chapter (see Figure  6.1) noted that trauma memories frequently emerge or are deliberately accessed in the context of imaginarily confronting perpetrators. Deliberately accessing episodic memories of painful events is also an important aspect of many interventions used throughout emotionfocused therapy for trauma (EFTT). This chapter focuses not only on accessing but also on exploring trauma memories in-depth as a separate or stand-alone task and intervention that can be used before, after, or concurrently with imaginal confrontation (IC) in the same session or separate sessions. This focus typically begins in the early part of Phase 2, and information gleaned in this process can serve as a reference for intervention and change in later sessions. The primary target of change in EFTT reexperiencing and memory work is the holistic and pervasive sense of the self as insecure or worthless that is automatically activated in current situations. As noted in Chapter 3 on different types of emotions, even though this core self-organization comprises cognitive, affective, somatic, and behavioral dimensions, the experience of vulnerability or shame is frequently not caused or preceded by other underlying cognitive–affective processes. Appropriate intervention requires processes that resemble those used in the counterconditioning of primary maladaptive

https://doi.org/10.1037/0000336-008 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  153

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fear. In EFTT, this involves accessing the primary maladaptive emotion structure or schemes (fear, shame) and associated sense of self, typically through re­experiencing trauma memories. Change occurs through simultaneously accessing alternative healthy internal experiences (e.g., adaptive anger at perpetrators, sadness for one’s suffering, self-compassion) to restructure the maladaptive sense of self.

THEORY The following subsections review the nature of trauma memories and describe the importance of reexperiencing trauma memories in recovery, the quality of productive trauma narratives, and change processes across theoretical orientations. The Nature of Trauma Memories First, recapping material presented in Chapter 1, trauma memories are thought to be largely nonverbal and sensorial—images, smells, and emotions, particularly fear, horror, helplessness—and stored in the right hemisphere. Memories of traumatic events are also frequently incomplete, with gaps in recall, and/or are vague and incoherent due to the intense arousal and narrowed focus of attention at the time of the event that interferes with processing. These factors, combined with the avoidance of trauma feelings and memories as a coping strategy, make it difficult for survivors to make sense of and formulate a balanced interpretation of traumatic events. Cognitive biases and messages from perpetrators attributing blame to victims exacerbate the problem. The reexperiencing related to memory work procedures is intended to address these features of trauma memory. Memory Reconsolidation and Emotional Processing The construct of memory reconsolidation is not new, but there is recent interest and research in this area (see Lane & Nadel, 2020). The basic premise is that memories of events are not laid down like a recording that can be replayed; rather, they represent dynamic constructions that evolve with each retelling of the story. This means the circumstances under which one recalls a memory (e.g., the presence of a compassionate therapist), how one elaborates unexplored aspects of that memory (e.g., feelings, previously unspeakable aspects), and how all these facets of meaning are related to self-identity will influence not only the formulation of the memory but also how it is “reconsolidated” or restored (Ecker et al., 2012). In short, contrary to popular understanding, there is not an “original memory” to be recalled. What one remembers is a reconstruction of the last recollection, which creates a more fluidly evolving reminiscence. However, this demands that one richly engage those memories. Memories of

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traumatic experiences are limited in how they can evolve when they are not verbally processed (kept secret)—this is the basic construct of emotional processing (Foa et al., 2019). Alternatively, if each retelling is done without adequate support, this can become a rigid rehearsal of “the same old story,” the maladaptive pattern of perceptions, feelings, and beliefs formed at the time of the event. Trauma symptoms and disturbance thus are perpetuated. The role of memory work in therapy, therefore, is to activate old memories and generate new content that can be incorporated during reconsolidation. Activating the trauma memory and retelling the story of what happened in a safe context with an empathic therapist who can direct attention to new detail of the experience can reduce memory gaps, coconstruct more adaptive meaning, and change the memory in a productive way. For example, in re­­experiencing the emotional significance of sexual abuse, the therapist might direct the client’s attention to their confusion as a child, their attempt to stop the abuse, or coercive statements made by the perpetrator. And exploring these can change the memory of self to someone who was not to blame. Thus, reconsolidation provides a neurological explanation for how memories can change both in the way one feels about them and also through the incorporation of new content into an existing memory. Emotional processing is one of the mechanisms that provides new content that gets infused into one’s recollections of the past so that memories are no longer what they once were. Quality of Productive Trauma Narratives The content and quality of client narratives about traumatic experiences reflect how these events have been encoded in memory and processed. Abundant research, beginning with Mary Main’s seminal work on the Adult Attachment Interview (AAI; George et al., 1985; Main & Goldwyn, 1984), supports the link between narrative quality and unresolved trauma. George et al. (1985), for example, found that narratives about attachment experiences told by clients with unresolved childhood trauma were characterized by incoherence (lacking in sequential order or meaning) and emotion dysregulation. Furthermore, these features of narrative quality predicted the “disorganized” attachment status of the clients’ children. An early review of several studies found that posttraumatic stress disorder (PTSD) symptomatology (i.e., unresolved trauma) before and after therapy was associated with trauma narratives lacking in coherence, emotional content, and insight (O’Kearney & Perrott, 2006). More recently, Callahan et al. (2019) described the link between PTSD and overgeneral trauma narratives lacking in specific episodic autobiographical memories. Similarly, a large body of research across diverse clinical and nonclinical samples supported the importance of emotional content in written trauma narratives and health outcomes (Pennebaker & Chung, 2011). Research specifically on EFTT supported both the quality (depth of experiencing, emotion) and content (specific emotions, views of self) of trauma narratives as

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predictive of treatment outcome (Khayyat-Abuaita et  al., 2019; Mundorf, 2013; Mundorf & Paivio, 2011). Angus and colleagues’ (2017) taxonomy of narrative subtypes introduced in the case conceptualization section of Chapter 4 is particularly relevant to client storytelling about traumatic experiences. To briefly review, “problem” narratives lack personal and emotional engagement—they are emotionally vacant or overly general, vague, and rehearsed, and/or are lacking in reflection (low level experiencing, described in Chapter 5). These types of storytelling are nonproductive because the core emotion structure or scheme is not fully activated and available for exploration and change. In terms of memory reconsolidation, these types of narratives have few new and adaptive elements, so change is minimal with the retelling, and maladaptive elements of the memory may be further entrenched. Therefore, the goal of reexperiencing trauma memories is to help clients shift from problem to more productive or “transitional” (Angus et al., 2017) storytelling that includes adaptive elements (feelings, needs, beliefs) and deeper levels of experiencing that are personal, affective, and reflective. Constructing a narrative that is specific and personal with a beginning, middle, and end (“play it like a movie”) can reduce memory gaps, overgeneralization, and incoherence to help the client make sense of traumatic experiences. Interventions that help clients reflect on the meaning (causes, effects on self and relationships, unmet needs) of traumatic experiences and coconstruct new understanding involve the deepest level of client experiencing. This new perspective will begin to be reflected in client “change” narratives at the end of the reexperiencing process. There is evidence that the presence of transitional and change narratives early in therapy, including in EFTT, indicating early access to adaptive information and perspectives, is prognostic of good outcome (Angus et al., 2017; Paivio & Angus, 2017). The following section delineates common and distinguishing features of trauma reexperiencing in EFTT compared with other major effective approaches to trauma therapy first presented in Chapter 1.

DIFFERENT APPROACHES TO MEMORY WORK There is agreement across different recognized treatment approaches that some form of reexperiencing trauma feelings and memories, in the context of a safe therapeutic environment, is necessary for healing and recovery. Thus, exposure and emotional processing are considered common change factors across different approaches. As noted in Chapter 3, traumatic fear is considered a primary maladaptive emotion or an overgeneralized conditioned response to fear cues. Once the fear or memory structure is activated, it can be exposed to new information or experiences that modify it. The process is similar for primary maladaptive shame, which is typically part of complex relational trauma.

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Many of the reexperiencing procedures used in recognized trauma therapies are based on Foa and colleagues’ (2019) classic prolonged exposure. This procedure involves the detailed sequential retelling of a single episode (e.g., an assault), repeated every session, with attention to associated sensory and emotional experience and beliefs. Standard cognitive behavior therapy emotion regulation strategies are used as needed. The purpose is to reduce PTSD symptoms. The client learns to tolerate the memory (habituation) and becomes aware of aspects of the event they were not aware of before. This new information helps modify the memory structure and counteract maladaptive cognitions such as self-blame. The standard prolonged exposure protocol has also been modified for survivors of complex trauma (e.g., Cloitre et  al., 2006). The approach includes an emotion regulation skills training phase before exposure and less intense exposure that begins with the least troubling memory. Eye movement desensitization and reprocessing therapy (EMDR; Shapiro, 2018) also begins with a stabilization phase before the reprocessing phase. This reprocessing involves simultaneous bilateral stimulation and solitary free association focused on the details of a specific event rather than sequential replaying. Because the effects of trauma are cumulative, EMDR exposure begins with the chronologically first traumatic event experienced by the client. Memory reprocessing occurs through discussion, at prescribed intervals, of new material that emerges in the free association task. This is thought to forge new neurological links between the unprocessed memory and more adaptive new information contained in other memory networks. Sensorimotor psychotherapy (Ogden & Fisher, 2015) is a promising approach that focuses on reducing the neurobiological effects of trauma (hyperarousal, numbing, muscle constriction). Following a stabilization phase, trauma reexperiencing can involve focusing on a particularly evocative aspect or “snippet” of memory (e.g., the worst part) rather than a sequential replaying. During the procedure, the therapist helps the client mindfully follow the hyperarousal sensations associated with the trauma memory while simultaneously experiencing an alternate positive embodied experience (e.g., grounding, calmness, empowerment) learned in the earlier stabilization phase. This is continued until the arousal subsides. It is thought to recalibrate the nervous system and associated neurobiological processes. Herman’s (1992) seminal narrative disclosure therapy is a psychodynamic approach that explicitly focuses on the healing therapeutic relationship as a corrective emotional experience and mechanism of change. According to Herman, stressful exposure procedures are contraindicated for repeated relational trauma in the context of attachment relationships. Rather, the therapist first helps the client tell the story of what happened, to “speak the unspeakable,” often for the first time. This gradually shifts to a focus on the emotional impact of events and an exploration of the meaning of events in terms of relationships and moral questions (e.g., “Why me?” revenge, forgiveness) and constructing a new interpretation of the experience. The emphasis in

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narrative disclosure therapy for complex trauma is on acknowledging, understanding, and mourning the many losses that occurred in attachment relationships. The approaches to reexperiencing memories of childhood trauma have several factors in common. First, except for prolonged exposure, they all involve gradual exposure and begin with establishing client safety. Second, in all approaches, clients are encouraged to tell the story of what happened with attention to sensory and perceptual detail and with emotional arousal that is adequate to activate the trauma memory fully. This makes maladaptive aspects of the memory or fear structure available for modification. Finally, all reexperiencing procedures involve accessing new information and experiences to change the activated trauma memory structure.

GOALS AND PROCESSES OF MEMORY WORK IN EFTT The following subsections delineate features of memory work as a distinct therapeutic task in EFTT. Client Disclosure Versus Memory Work as a Task Episodic memories that spontaneously emerge in the context of therapy processes or are deliberately elicited help concretize experience and activate emotion schemes (e.g., “Do you remember a time or incident?”). However, the term trauma reexperiencing refers to deliberately emotionally reliving events to process them fully. Traditionally, these memories concerned experiences of fear and terror, such as the unpredictable rages of an alcoholic father, experiencing or witnessing physical beatings by a caregiver, or the terror of a mother’s violent suicide, as in the case of the client Monica. However, childhood trauma frequently involves feelings not only of fear but also related to shame. Clients feel insecure and vulnerable to harm, abandonment, or rejection because they feel bad, worthless, defective, or unlovable. This is the case for most of the client examples presented later in this chapter and throughout this book. In the early phase of therapy, beginning in Session 1, clients are encouraged to disclose memories of traumatic experiences and tell the story of what happened to them. Therapist acceptance, compassion, and empathic responding reduces client shame and isolation and strengthens safety and trust. The content and quality of client narrative disclosure also assist in process diagnosis, assessment, and case conceptualization and thus in establishing therapeutic goals. Client disclosure in the early phase of therapy is thus the first step in productive memory reconsolidation and emotional processing because it involves a new client experience of telling their story to a compassionate, empathically responsive other who has professional expertise. However, this early disclosure is distinct from explicit reexperiencing of painful and traumatic memories in the later phase of therapy. Table 7.1 summarizes those distinctions.

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TABLE 7.1.  Distinguishing Early Disclosure From Memory Work Early disclosure (Phase 1) Establish trust Elicit information Begin gradual exposure (approach pain) Assess narrative quality

Memory work (Phase 2) Promote emotional processing and change Evoke and intensify emotion Deepen experiencing Promote productive narrative quality

Variations of Memory Work as a Distinct Task in EFTT Memory work as a stand-alone task in Phase 2 of therapy can take two forms. The common purpose in both is to bring the experience alive—increase emotional engagement, activate the core maladaptive emotion scheme and sense of self, and access alternative adaptive resources (feelings, needs, self-protective impulses) to restructure the memory and change the emotion scheme and sense of self. The first and most frequently used form of memory work in EFTT involves brief activation and exploration of a particularly evocative memory fragment (e.g., the worst part) as a subtask in the context of other tasks. The specific purpose is to deepen emotional engagement whenever clients’ storytelling about important childhood or recent experience is vague, overly general, or emotionally constricted. Such vivid, emotionally alive memories are emblematic of a client’s sense of self and can be referred to repeatedly over the course of therapy. The second form of memory work in EFTT involves detailed sequential replaying of an event from beginning to end. This is an emotion-focused therapy “imaginal reentry” task that shares features with classic prolonged exposure for PTSD (Hembree & Foa, 2020) and systematic evocative unfolding (SEU) for clarifying problematic reactions, which is a standard emotionfocused therapy intervention (Elliott et al., 2004). Both procedures involve slowing down the process of recall and paying new attention to the sensorial detail and internal experience associated with a memory. However, these procedures significantly differ in purpose. The purpose of SEU is to identify the specific stimulus or trigger and its associated meaning to understand one’s reaction in a situation. For example, a client who had decided to end a destructive romantic relationship ended up agreeing over the telephone to meet with her ex again. She was disturbed and puzzled by this decision: “I don’t understand why I would agree to this when I know better!” In systematically replaying the events leading up to and during his phone call, she recalled the comforting and soothing sound of his voice, which triggered a deep longing to experience this comfort again. The SEU procedure helped her understand why she agreed to meet with her boyfriend, despite her decision to end the relationship. Although, like SEU, one purpose of trauma reexperiencing might be to help clients better understand their reactions and behavior during traumatic events (e.g., why they did not fight back or disclose to others) by reducing memory gaps. Most often, the purpose of reexperiencing

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trauma memories is emotional processing—to change or reconsolidate the memory itself. Core Features of Memory Work in EFTT Interventions include evocative empathy during narrative processing and imagery and imaginal reentry techniques to increase emotional arousal and thus activate the emotion scheme. As in imaginal exposure and systematic evocative unfolding, memory work in EFTT includes slowing down recall and directing attention to and fleshing out sensory and perceptual details of the event and internal experience at the time—bodily experience and, particularly, feelings (fear, shame) and associated meanings (views of self, others, events). However, a critical feature of memory work in EFTT is that it involves simultaneously accessing and strengthening healthy adult self-protective resources (e.g., “How do you feel now as an adult remembering yourself as a child in that situation?”). This almost always evokes adaptive anger at perpetrators, holding them accountable for the harm and/or sadness for one’s suffering and compassion for self. Another core feature of memory work in EFTT is that the task is sometimes used to intentionally generate alternative adaptive scripts or narratives. This EFTT approach to reexperiencing trauma memories resembles other imaginal reentry techniques. For example, imagery rescripting (e.g., Arntz et al., 2007) asks clients to imagine reentering the trauma scene accompanied by a stronger and protective other (or part of self) who can provide verbal or nonverbal protective and empowering responses while the client reexperiences the traumatic event. Similarly, dream rescripting (e.g., Kellner et al., 1992) that involves the client changing the ending of a trauma nightmare to something more powerful and satisfying can be integrated into EFTT (Paivio & Shimp, 1998). The important point in all these procedures used in EFTT is that the emotion scheme or memory structure is activated, and the client feels the shame and/or fear of the traumatic event and simultaneously experiences the more positive response. This is always done in the context of a safe therapeutic relationship and only once the client has some access to adaptive internal resources, including emotion regulation capacities.

PRACTICE GUIDELINES FOR EFTT MEMORY WORK The following sections specify several in-session markers for trauma memory work and reexperiencing in EFTT and delineate steps in these procedures. One caution concerning memory work is the issue of false memories. The aim of memory work is to discuss abuse as clients remember it. Therapists should note that it is potentially harmful to suggest to clients that they may have repressed memories of abuse (Patihis & Pendergrast, 2019). The obvious pitfall is that, for many reasons, clients may have memory gaps or fragments of

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early memories that are incoherent. Such memory gaps can be understandably disconcerting to clients. Therapists should validate that concern, explain that memory gaps are commonly associated with growing up in an environment of chaos or fear, and reassure the client that therapy will focus on exploring the memories they have access to. Markers for Memory Work There are three general markers or in-session indicators for the task of memory work: (a) memories are shallow, (b) memories are avoided or warded off, and (c) memories involve a sense of self as defective or damaged. Regardless of the level of involvement—focus on a memory fragment or detailed sequential processing—steps in the memory work procedures are the same, although the latter process is longer. Furthermore, in either of these variations, memory work almost always incorporates the IC or evocative exploration (EE) interventions and/or a self-soothing task whereby the client expresses comfort and compassion toward their imagined self as a child. The latter intervention will be detailed in Chapter 10. Steps in the Memory Work Task Once markers for memory work or reexperiencing have been identified, the following practice guidelines support the task. Step 1. Collaborate on Exploring Specific Traumatic Experience Like all EFTT tasks, trauma reexperiencing begins with explicit client–therapist collaboration on the task. This can be as simple as asking clients if they can recall a specific event, such as an example of a recent or childhood experience, then implicitly or explicitly agree to explore their internal experience at the time of the event (e.g., “So hurtful. Can you say more about what it was like for you on the inside hearing those cutting words ‘you always screw up’?”). Note the therapist’s repetition of the stimulus to maintain emotional engagement. Sequential reexperiencing requires explicit collaborative agreement on the task of slowing down and recalling in detail from beginning to end a specific traumatic event and associated internal experience. The therapist validates client reluctance and addresses fears they may have about opening these wounds and, at the same time, stresses that this is the route to healing. The therapist provides encouragement, reassurance, and support (e.g., “I will help,” “We will go at your pace”) and a rationale that is tailored to the individual client. Reexperiencing in a safe therapeutic environment can help the client feel no longer “alone with this ugly secret” or that they have “shed light on those dark corners to help make sense of those experiences.” In all instances, reexperiencing procedures activate painful maladaptive feelings and beliefs formed at the time so they can be tolerated, reflected on, understood, and challenged. This allows the trauma memory to evolve and change.

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Step 2. Maintain Optimal Arousal Reexperiencing distressing traumatic events requires optimal arousal to activate and explore emotion memories without being overwhelmed and shutting down. Both sequential retelling and activating the most evocative fragment of a memory are intended to activate emotional pain and distress. It is important to distinguish distress, which is necessary and adaptive, from dysregulation, which is not. The distressed client is visibly upset in reaction to accessing painful memories, but with encouragement and support, they can continue speaking. Intervention in this instance includes affirmation of vulnerability to reduce anxiety (e.g., “I know, it’s scary to feel so exposed”), encouragement to continue, and reassurance (e.g., “That’s good—stay with it; this is so important”), as well as brief breathing or grounding instructions (e.g., “Try putting your feet on the floor, feel your bum in the chair”; see Chapter 2) to assist with present-centered awareness and regulation as needed. The goal is to help the client continue. When clients begin to distance themselves from emotion, interventions, again, include validation and encouragement to continue, along with evocative empathy or imagery techniques (e.g., “Do you see yourself sitting there, this innocent little 5-year-old child?”) to activate the emotion memory. When dysregulation or avoidance are so extreme the client is unwilling or unable to continue, it requires shifting from reexperiencing to a separate emotion regulation task. Strategies for deepening emotional engagement and experiencing were presented in Chapter 5, and strategies to reduce client avoidance are the specific focus of the following chapter. Step 3. Evoke and Explore Episodic Memory The role of the therapist in reexperiencing trauma memories is to direct attention to core features of the memory and help the client tell a story that is concrete, specific, personal, emotional, and coherent. These are the features that will facilitate memory reconsolidation. Clients can be encouraged to recall the context, describe what happened in as much detail as necessary to evoke the memory, and elicit an obvious emotional reaction. Sequential processing interventions help the client tell the story in detail, with a beginning, middle, and end that fills in memory gaps and promotes coherence. Questions and prompts can elicit sensorial detail and specific words the perpetrator said or the message implied (e.g., “I am doing this [beating brother] for his own good,” “I wish I’d aborted you”). Importantly, therapist empathic responses provide support and direct attention to and evoke client reactions and internal experience during the event. Therapists are empathically attuned and responsive to client processes in the present—content, vocal quality, facial expression, breathing, shaking, sweating—as they tell the story of what happened in the past. Step 4. Activate Maladaptive Sense of Self The central objective in evoking the memory is to activate emotional experiences in the situations and/or the core maladaptive sense of self (e.g., as dirty,

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complicit, to blame) formed at the time of the traumatic event. Importantly, interventions during the retelling also direct attention to details of the event or client experience at the time that can counteract that sense of self. For example, therapists can highlight the client’s attempts to protect themself (e.g., hide, escape, protest, tell someone); their powerlessness and innocence as a child in the situation; their feelings of anger, disgust, and confusion at the time; or the perpetrators coercive or threatening words that rendered them powerless. In instances of sexual abuse, the client may recall liking the attention at the time, and interventions help the client identify unmet needs that made them vulnerable (e.g., starved for attention). Some clients report experiencing sexual pleasure at the time, which generates guilt. In these instances, interventions need to highlight their innocence at the time and provide information about normal sexual response. This type of guilt may need to be processed as a separate task, which is the focus of Chapter 9. Reexperiencing a fragment of the worst, most emotionally painful part of the event is less detailed in terms of context. The purpose is not to reduce memory gaps and promote coherence but to vividly evoke feelings and beliefs at the time of the event. Step 5. Access Adaptive Adult Capacities Once clients deeply experience the emotional pain of early traumatic experiences and experience themselves as innocent victims, intervention involves accessing alternative adult self-protective responses—usually, anger at the perpetrator and/or compassion and sorrow for the self and associated wants, needs, and action tendencies. These adaptive emotional experiences will be used in other tasks (IC or EE) to undo and transform maladaptive emotion. However, adaptive emotions need first to be recognized, described, and acknowledged. These can be strengthened if they spontaneously emerge or can be deliberately activated (e.g., “How do you feel right now remembering yourself as a child?” “How do you feel right now remembering your father saying such a cruel thing to you?”). Step 6. Shift to IC or EE and/or Self-Soothing Once adult self-protective responses have been accessed (or to help access these responses), the final step in reexperiencing and the hallmark of EFTT is to help the client imaginarily confront perpetrators in IC or EE, express feelings and meanings, and hold them accountable for harm (e.g., “What would you say to him now remembering what he did or said?”). This follows the guidelines presented in the preceding chapter on IC. Alternatively, if the situation involved self-blame and newly accessed sorrow for the self, a selfsoothing intervention can be used in which the client expresses compassion or comfort to themselves as a child. Because this intervention shares features with two-chair interventions described in the following two chapters, complete guidelines for implementing the self-soothing procedure are presented at the end of Chapter 9.

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MEMORY WORK WHEN MEMORIES ARE SHALLOW The first major marker for doing memory work occurs when key memories are shallow, when the client does not richly engage in their recollections of what happened. Prototypical examples of this include (a) limited emotional engagement; (b) vague, overgeneral, or incoherent storytelling; and (c) lack of clarity or confusion about recent or past trauma reactions. All these are indicative of limited access to specific autobiographical memories. Both PTSD and depression, which is highly comorbid with PTSD and complex traumatic stress disorder, are frequently characterized by limited access to autobiographical episodic memories. This is evident in vague overgeneral storytelling. In the case of PTSD, this can be a function of attentional, encoding, and processing impairments associated with high levels of fear and arousal during the traumatic event, coupled with chronic avoidance of painful and threatening memories. In the case of depression, several studies have examined the neurobiological substrates underlying autobiographical memory dysfunction in major depressive disorder. Although the precise mechanisms remain unknown (Köhler et al., 2015), vague, overgeneral memories associated with depression have been explained in terms of avoidance of emotional pain (Hamlat & Alloy, 2018). Several interventions have targeted these memory deficits because they interfere with therapeutic change. One approach to helping clients access episodic memories involves group memory training (Callahan et al., 2019), in which clients start by recalling recent neutral or positive events and gradually move on to recall recent negative experiences. Similarly, in EFTT, therapy can focus on helping the client access specific autobiographical memories of recent distressing events in which the core maladaptive emotion scheme is activated and deeply reexperience the emotions involved (see the guidelines for reexperiencing and memory work). This could spontaneously activate memories of childhood experiences, or the therapist could explicitly ask about childhood experience with similar painful or threatening feelings. If specific episodic memories are not available, intervention needs to identify and address the block—high levels of anxiety in session, for example, or chronic avoidance and distancing from painful emotional experience. Key Intervention Principles While all aspects of experiential work are relevant, two intervention principles stand out when beginning work with shallow memories. These are memory evocation and exploration and directing the client’s attention to internal experience. Memory Evocation and Exploration Recalling the external details of an event is important to evoke core emotion schemes. Once evoked, reexperiencing tasks involve deliberate exploration of

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both the external details and internal experience at the time of the event. Again, effective memory evocation and exploration involve deliberately promoting recall of memories that are concrete and specific (e.g., where, when, and the precise words of the perpetrator), personal (e.g., the use of “I” language, personal reactions), rich in sensorial detail, emotional, and reflective (e.g., perceptions, interpretations, effects). These interventions target dimensions of productive client storytelling that might be minimal or absent and thus deepen emotional engagement and experiencing. Interventions that help the client tell the story from beginning to end can help reduce memory gaps, promote coherence, and help them make sense of traumatic events. External detail (e.g., “the look of contempt on her face”) also activates maladaptive feelings, perceptions, and interpretations, making them available for exploration and change. External detail can also evoke adaptive internal experience (e.g., the client described next says, “The smell of him—gak!”) for integration into maladaptive emotion schemes and memory reconsolidation. Direct Attention to Internal Experience Client storytelling about traumatic experiences is frequently focused on external events—the plot and characters involved in what happened. However (except for fostering coherence), external detail is important primarily in its stimulus function—to evoke internal experience at the time of the event. This resembles the stimulus function of the imagined other in IC or EE. Evoked internal experience includes maladaptive thoughts and feelings, so they can be examined and changed, as well as adaptive experience (e.g., anger, protest, attempts to avoid harm) that will help counteract maladaptive feelings and beliefs and thus transform a maladaptive sense of self. Interventions that direct attention to internal experience (see Chapter  2) include empathic responding to or conjecture about implied thoughts, feelings, and needs or questions and directives to attend to internal experience, often beginning with bodily experience. Case Examples of Working With Shallow Memories The following case examples illustrate memory work with each of the examples of shallow memories described earlier. Limited Emotional Engagement Clients can tell the story of what happened and sometimes identify emotion words but have only an intellectual understanding of the impact of events or low arousal. An example is the client Mark who had a history of cold, rejecting anger and limited access to vulnerable experience (Paivio & Angus, 2017). During Session 1, Mark disclosed episodes of beating by his father and begging his mother’s forgiveness for hours. This was told in a matter-of-fact manner with flat affect. The therapist’s empathic responses to his anger and pain did not deepen his experiencing. He and the therapist collaborated on

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deepening emotional engagement as a focus for therapy. To that end, this episodic memory was deliberately accessed and referred to repeatedly over the course of therapy. During the first IC, introduced in Session 4, Mark admitted that he was “only saying stuff, not feeling it.” When the therapist asked how he felt inside, he said, “All uptight, sweating, heart racing.” This discrepancy between his internal experience and outward presentation was a marker for initiating memory work with evocative fragments to reduce overcontrol and more fully activate emotional experience. THERAPIST:

A lot going on inside, being stuffed, so angry at her for good reason, for treating you so badly.

The therapist suggested focusing in depth on the episode he described in Session 1—being beaten by his father, then having to beg his mother’s forgiveness. CLIENT:

I had to kneel in front of her for something trivial, begging my mother’s forgiveness for hours, and she refusing to forgive.

THERAPIST:

What was she saying—do you remember?

CLIENT:

“You don’t mean it; you don’t care about us; you’re just using us.” I keep saying, “I’m not using you; I do care.” Like, please believe me. The whole time, she’s lying down on the couch, looking at the TV.

Here, the client provides a vivid description of the external scene, and the therapist directs attention to the client’s internal experience. THERAPIST:

Not even looking at you. You must have felt so . . .

CLIENT:

I felt like I was charged with a murder, going to jail.

THERAPIST:

No way out, convicted, powerless.

Here, Mark shifts to anger and blaming—“what a nasty bitch”—and the therapist helps him stay with the memory and sensorial details of the mother to deepen emotional engagement. THERAPIST:

Can we stay in the memory?

CLIENT:

My mother is ranting and raving.

THERAPIST:

Okay, switch chairs; be your mother [stimulus to evoke response], rant and rave. How did she sound? Do it. What is it like?

CLIENT:

Her voice is like a knife in your back.

Mark then collapsed, stating, “I can’t do this very well.” The therapist bypassed this interruption and encouraged him to stay focused on the memory. THERAPIST:

Stay with it, Mark, focus. You are doing fine; keep going— mother ranting and raving. What are you feeling imagining her? Really check inside; stay here [hand on heart], whatever it is.

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CLIENT:

My mother hates me, and the hole in my heart is getting bigger and bigger [shift from anger to sadness].

THERAPIST:

A big hole in your heart, feeling like your own mother hates you—so painful for you as a boy.

Accessing this episodic memory of the event with his mother, along with the therapist’s empathic responses and expressions of compassion, increased Mark’s awareness of his vulnerable childhood experience. This, in turn, helped increase his sense of entitlement to unmet needs. Mark and his therapist returned to this episodic memory in later sessions, this time with a focus on the beatings by his father. This intervention involved the sequential unfolding of the memory. The therapist asked Mark to recall in detail the events leading up to the strapping, his feelings of fear and powerless, and his feelings afterward, crying alone in his room. This helped increase Mark’s experiential awareness of the damaging effects of these events on his sense of self and close relationships. CLIENT:

I was crying, yelling, begging, pleading like I was going to be shot.

Mark’s use of vivid metaphor in this statement and later in the excerpt provides a window into his internal experience that helps the therapist empathically respond. THERAPIST:

Begging for your life.

CLIENT:

I have kids—how could anyone do that? I didn’t deserve that. I deserved to be treated like a human being.

THERAPIST:

Exactly. How awful for you, Mark. Do you remember how you felt at the time? [direct attention to internal experience]

CLIENT:

I felt completely abandoned, helpless.

Here, Mark’s vocal quality was inwardly focused as he was experiencing the impact of these childhood experiences. They referred to this specific memory (and others) repeatedly as emblematic of his experience as a child. It opened the door to vulnerable feelings of sadness for what he had missed, unmet needs for love and support, and the damaging effects on his sense of self and relationships. These experiences, in turn, contributed to increased self-compassion rather than self-loathing: “I can’t imagine doing that to my own children; it would crush them, break their hearts.” Vague, Overgeneral, Incoherent Storytelling Another example of impoverished narrative quality is storytelling that is overgeneral and vague, with few concrete or specific details or examples (e.g., a client said, “I always mess up, and my father—I mean, the way he talks to me, like, even my sisters—it was always like that in our house”). These are markers for accessing a concrete, specific, episodic memory fragment to evoke

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core emotion schemes and deepen experiencing (e.g., the therapist asked, “Do you recall a specific event, a time when you messed up, what exactly your father said?”). However, an indicator for sequential processing (described earlier in this chapter) is narrative incoherence, such that a reported memory of an event lacks sequential order or does not make sense. This was observed with a client who had a lifelong history of feeling unwanted, rejected, and unlovable stemming from childhood physical and emotional abuse by both parents. This sense of self and painful feelings were triggered by his recent unwanted marital separation. In early sessions, the client repeatedly referred to an incident of sexual assault by a group of older children when he was left alone and unprotected by his parents. However, the story was scattered, and the context and details were unclear. The story of the assault was mixed up with vague references to self-harm, his mother withholding birthday presents, and his wife withholding affection. This type of incoherence required sequential processing of the sexual assault to help the client make sense of this pivotal event and its role in his sense of self and life story. Lack of Clarity, Confusion About the Recent or Past Trauma Reactions Another marker for memory work is client confusion or lack of clarity about their reactions to past traumatic events or current situations resembling the trauma. The client continues to be troubled by this lack of understanding. This resembles markers for SEU (Elliott et al., 2004), described in an earlier section. For example, a client who was abused by a priest over several years repeatedly questioned, “Why did I go back?” The therapist initially conceptualized this as a marker for self-blame, and the middle phase of therapy began with a standard emotion-focused therapy two-chair dialogue to address this self-critical conflict (see Chapter 8). However, the two-chair intervention was ineffective in bringing about a shift in the client’s experience. Interpreting the client’s statement as “I don’t understand why I kept going back” as a marker for confusion about his childhood reactions was more helpful. Following the emergence of the client’s self-questioning (“Why didn’t I quit the church?”), therapist and client agreed to engage in memory work to help the client understand his reactions better. The therapist asked, “There must have been many times when you tried to figure out what to do. Do you remember a specific time?” The therapist then helped him recall in vivid detail one episode of leaving the priest’s residence, going to a neighborhood park, sitting alone on a bench, and trying to figure out how to deal with the situation. She directed his attention to his thoughts and feelings as he sat there on the park bench. He recalled wanting to tell his mother but feared she (and anyone else he told) would not believe him or blame him or, given the recent death of his father, that he would wound her further by disclosing the abuse. He recalled considering quitting the church but then thinking that there was no way he could do that—he would be found out, questioned, and doubted. He reexperienced

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himself as a powerless, trapped boy with no good options except to try to avoid the priest as best he could. The therapist asked him for examples of how he tried to avoid the priest—he came late, left early, and hid whenever he saw the priest—which helped to empower him. She also asked how he felt about himself now as he remembered that episode of sitting on the park bench. He reported a sense of relief, knowing he did try his best to deal with an impossible situation; it helped explain his decision to handle it secretly and on his own. Reexperiencing in an emotionally alive way helped the client understand his dilemma at a gut level and have compassion for himself as a powerless boy rather than blaming himself. Memory work to generate new information in this way is particularly suitable for clients who have been profoundly neglected as children. Neglect, unlike abuse, involves the absence of responsive information. Neglected children grow up with the implicit sense that there must be something wrong with them but are unclear what this might be, and they are constantly searching to figure it out. In therapy, these clients can be cautious or inhibited, have difficulties with experiencing, and often look to the therapist for guidance. However, unlike the social anxiety from emotional abuse, which primarily concerns fear of an anticipated negative evaluation, the experience of neglected individuals tends to be one of uncertainty about internal experience and what is expected of them. Therapist interventions provide the emotion coaching and mirroring they did not receive in childhood. These include offering tentative guesses or conjectures about a client’s experience while exploring episodic memories until the client can recognize their self-experience. An example is a client, Helen, who recalled her father’s indifference when, with pride, she showed him her glowing report card. The therapist began with a reflection: “Proud of your report card. You must have been so dis­ appointed by his reaction? Slinking off to your room and sitting by yourself.” The therapist then helped her explore tacit meanings: “What was going on in your mind? How did you feel . . . confused or sad, maybe angry? What was your understanding of why he behaved that way? Somehow it was something about you—what did you imagine was wrong with you? How did you cope with those painful feelings?” This is the process of promoting experiencing to increase understanding and construct new meaning. In Helen’s example, she recalled feeling so disappointed, alone, and confused, trying to figure out what was wrong with her that her father was so disinterested. She thought she was somehow boring or weird, but there was no clear answer, just a perpetual feeling of inadequacy and uncertainty about who she was and how to get the attention and recognition she desired. Change occurs first through accessing core maladaptive beliefs (e.g., “I must be weird”), followed by alternative healthy processes. For Helen, change eventually occurred through the emergence of speculative questions (“Maybe there was nothing wrong with me; maybe it was just his weirdness? Hmm, I don’t think I did anything to deserve his coldness”). Following this, Helen shifted to feelings of sadness through the emerging awareness of unmet attachment

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needs (“More than anything, I wanted his approval. I feel so sad that I never got that. I was such a confused little kid, trying so hard to figure out how to please, always failing, always disappointed. That’s how I’ve lived my life.”). This was the beginning of emotional transformation.

MEMORIES ARE WARDED OFF Another major in-session marker for memory work occurs when clients are desperately trying to ward off and avoid intensely painful or threatening memories. Prototypic examples of this kind of marker include when clients suffer (a) intrusive memories and flashbacks and (b) when clients feel as if what happened is “unspeakable.” Some clients explicitly express reluctance or unwillingness to disclose details of trauma and abuse (often sexual abuse or some form of humiliation) in therapy. The therapist first needs to understand and validate the reason for reluctance— it is too disgusting or embarrassing, or they fear being overwhelmed—but not shy away from reexperiencing to promote emotional processing and recovery. The therapist provides a rationale (e.g., “These secrets eat away at you”), reassurance (e.g., “When you are ready,” or “We can stop any time you like; you are in the driver’s seat”), and gradual engagement with fragments of memory rather than sequential processing. Markers for introducing recall of specific episodic memories can occur in the context of processing current issues that obviously stem from past traumatic experience (e.g., “Those sound like very familiar feelings,” “You are vulnerable to those feelings being activated again and again,” or “Your buttons keep getting pushed”). Key Intervention Principles Building on the importance of the intervention principles presented earlier, two more principles are essential when working with memories that are warded off: modulation of emotional intensity and affirmation of client vulnerability. Modulation of Emotional Intensity This overarching intervention principle is aimed at ensuring optimal emotional arousal within the client’s “window of tolerance” so that emotion memories can be explored. Of course, responses such as empathy or the use of physical grounding techniques are essential to reduce arousal and distress so that clients are not overwhelmed and retraumatized. Importantly, however, effective intervention also involves intensification responses to evoke emotional experience that is not fully alive (e.g., “feeling like a piece of garbage”) and maintain emotional engagement during the exploration process. Sometimes maintenance responses simply say out loud what the client is reluctant to say without “tip-toeing” (e.g., “So the very person you needed the most actually wanting to hurt you”).

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Affirmation of Vulnerability When clients approach the emotional pain and fear of trauma memories, they feel extremely vulnerable. They demonstrate verbal and nonverbal signs of trepidation and anxiety at the suggestion or introduction of reexperiencing procedures. Interventions that affirm, acknowledge, and validate their current experience of vulnerability help them feel seen and reduce isolation and anxiety, so they feel safe enough to tolerate and explore the memories. The general rule of thumb is to first affirm, then explore. Of course, the accompanying intervention principle is to provide explicit encouragement, reassurance, and support. Case Examples of Working With Memories That Are Warded Off Indicators of warded off or avoided memories include client reluctance to disclose details of the trauma, finding them “unspeakable,” and PTSD intrusive symptoms. The following case examples illustrate memory work with each of these processes. Speaking the “Unspeakable” The experience of traumatic victimization is profoundly humiliating and alienating. Thus, many clients come to therapy having never disclosed details of what happened. They have been unable to speak about the trauma out of shame, fear of judgment, not being understood, and sometimes, not wanting to cause distress to others. This was the case with the client Monica, whose process of therapy has been described throughout the book. In early sessions, she disclosed what happened in a general way, confronted her mother in IC (see the previous chapter), and talked about the devastating effects on her and her family. During Session 5, she also described her mother’s suicide as “utterly unspeakable” and reported that she had never told anyone the details of what happened the night she found her mother dead. This was a marker for helping her tell the full story of what happened, so she was “no longer alone with this ugly secret.” In the following excerpt (Paivio & Angus, 2017), therapist responses provide support but go beyond facilitating simple disclosure (see Table  7.1). Responses deliberately help Monica remain focused on the sequence of events that frame the suicide and highlight the emotional impact of these events to facilitate more complete processing. CLIENT:

I was walking up the sidewalk and, um, it was quiet, and I open the front door very carefully and listen—so quiet, just the sound in my eardrums [experiential awareness].

THERAPIST:

This deafening silence [evocative empathy].

CLIENT:

I’m thinking this is really berserk because, usually, my sister would be there. [Therapist: Mm-hmm.] And I took my boots off, and I went down into the kitchen, and I saw my mother’s

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foot first, and I was in absolute shock and not knowing what to do. THERAPIST:

And your heart almost stopped [evocative empathy].

CLIENT:

And I started screaming for my sister, and I was frightened to call anybody because you know your own business stays within the four walls of your house so. . . . [Therapist: Sure.] I’m sure it was only a minute, but it seemed like 10 hours.

THERAPIST:

So, then you walked in and saw what actually happened [return to sequential processing].

CLIENT:

I tried waking her up, and I’m just shaking her and shaking her and trying to wake her up and thinking, you know, oh, God, what do I do, who do I call, what do I do?

THERAPIST:

Mmm, the horror of it [evocative empathy].

CLIENT:

So, the first thing I did—I called my uncle, and he came over. My heart goes out to him, thinking about it now; I can’t imagine what it must have been like coming on that scene.

This detailed telling of the sequence of events with sensory and perceptual detail, emotional reactions, and interpretations provided a more complete emotional processing of the memory as well as a corrective emotional experience with the therapist as ally and witness, reducing isolation and shame. Intrusive Symptoms PTSD intrusive symptoms (i.e., flashbacks, nightmares) often subside once the client begins to disclose, in the early phase of therapy, what happened to them as children. However, one obvious indicator for explicit reexperiencing of trauma memories is the persistence or reactivation of these intrusive symptoms, indicating the trauma is not fully processed. This processing can occur through imaginal exposure to trauma memories in therapy and/or exposure to recent traumatic events. In one case example, a client was exposed to extreme family violence as a child at the hands of her father, including insults, angry rages, being beaten, and not being protected by her mother. The client had become a successful professional but continued to experience depression, low self-esteem, inability to assert herself, and activation of PTSD symptoms at any loud expression of anger by others. This was heightened now because her brother had moved into her family home, and although he was not physically violent, he flew into loud, angry tirades. Therapy was a process of gradual exposure to painful childhood experiences to help enhance empowerment and access adult self-protective resources and apply these to her current life. The intervention focused on two fragments of memory that stood out for her: her father repeatedly calling her “stupid, as stupid as a pig” and him coming after her with a meat cleaver. Memory work began with the least threatening episode—confronting

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her father in IC about his insults. This helped empower her to reexperience and process the more terrifying incident of being threatened with a knife. Initially, this memory of being threatened evoked terror, crying, shutting down, and dissociation. The intervention first provided physical grounding in the present and safety of the therapeutic relationship. When the client began to collapse and sob, the therapist validated her vulnerability and explicitly encouraged her to stay in the present, in her current adult self, and recall details of the event from that perspective. The therapist said, “Yes, you were a powerless child; you could not protect yourself at the time. But you are an adult now, a grown woman. I’m encouraging you to put your feet on the floor, sit up straight, and take some deep breaths.” Once the client complied and was calmer, interventions returned to the memory and evoked adaptive anger expression: “Great, now speak from that perspective. How do you feel now, remembering him terrorizing you as a child? What kind of a father threatens his child with a meat cleaver?” After several sessions, she was able to confront her father in IC and hold him accountable for his violence. The client asserted, “What you did was wrong. Your war trauma did not give you the right to terrorize your child. You were a terrible father. You should have gotten help.” Later sessions applied these strategies to reduce automatic fear reactions and set boundaries in her relationship with her brother.

MEMORIES OF SELF AS DEFECTIVE OR DAMAGED The final major marker for the task of memory work concerns the content of core memories. The salient feature is the client’s explicit and deeply painful experience of self as somehow intrinsically defective and therefore the cause of the abuse or irrevocably “contaminated” or damaged by it. These memories can activate internalized self-invalidation or doubt, skirting around or minimizing the painful “truth” about self and events. At other times, this core maladaptive self is explicitly activated in current situations. Key Intervention Principles For memory work when the recollection is of a defective or damaged self, two intervention principles of present-centered awareness and symbolizing meaning are particularly relevant. These are in addition to issues discussed earlier. Present-Centered Awareness Reexperiencing is not regression. Interventions help clients recall from their present adult perspective rather than collapse into the vulnerable, helpless child they were at the time. This is also essential in preventing and recovering from dissociation: Clients learn to maintain distance from overwhelming experiences by staying in the present moment as they recall the past in an increasingly alive way. Interventions importantly ask clients to focus on their

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current adult reactions and emotional responses to reexperiencing themselves and perpetrators during past traumatic events. The goal is to highlight and integrate adaptive self-protective resources (e.g., “I was so innocent, scared. I needed help”) and thereby change the maladaptive sense of self and foster productive memory reconsolidation. Symbolizing Meaning Detailed recall of the sequence of events can promote coherence, which is the first step in meaning making. Interventions that help clients articulate the meaning of traumatic experiences also involve specifying the damage done to the self and the effects of this damage on the self and relationships over the years. Interventions also need to help clients articulate the meaning of adaptive experiences at the time of the trauma, including anger, disgust indicating rejection and a desire to distance the self, sorrow for the self, and acknowledging losses and what was missed. Case Examples of Working With Memories of a Defective or Damaged Self The following case examples illustrate EFTT memory work intended to activate and change a maladaptive sense of self formed at the time of the trauma. Internalized Self-Invalidation One of the features of childhood abuse and neglect is environmental invalidation, which fills one with uncertainty and self-doubt about what is going on and contributes to clients’ insecure sense of self. For example, the client Claire, who had been molested by her brother, was infuriated by her parents’ invalidation when she disclosed the abuse to them. This activated her selfinvalidation and doubt about whether she was exaggerating and “crazy” and her chronic struggle to trust her experience and perceptions. Session 5 began with an IC in which the client confronted her parents and expressed her refusal to “forget it.” This was a marker for introducing memory work to reduce minimization, “tell your truth,” and strengthen confidence in her perceptions. The therapist asked her to tell her imagined parents “exactly what happened to you. Tell them what they don’t want to hear” and encouraged the client to remember a specific incident of molestation. The detailed sequential account of oral sex from beginning to end brought home the reality of what happened to her as a child. This began with Claire recalling her anxiety and trying to be “Miss Busy” so her brother would not notice her. The therapist’s empathic responses highlighted her attempt to avoid harm, used the term “obeyed” to reinforce her compliance rather than complicity, and directed attention to her dislike of the sex at the time. This helped reduce self-invalidation and minimization of harm. She reexperienced herself as a vulnerable, innocent, frightened child who did not want the abuse but went along with a powerful, coercive other. The therapist helped her simultaneously use her

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self-protective impulses as an adult—being angry at the violation, holding her brother fully responsible for harm, and feeling compassion for herself as an innocent child. At the end of the session, Claire said it was hard to relive that painful scene, but for the first time in her life, she felt like she could get over it. This specific memory work was not repeated in therapy, but it was referred to whenever self-doubt and questioning her complicity in the abuse emerged again. Core Sense of Self as Defective or Damaged One of the features of unresolved trauma is that the emotion memory and a maladaptive sense of self are frequently activated in current situations. An example is the client Rachel who came to therapy to focus on issues of sexual molestation as a child at the hands of a babysitter, as well as with her emotionally abusive and neglectful mother who failed to protect her. The first four sessions focused on issues with her mother, with whom she still had a relationship. At the beginning of Session 5, Rachel was highly distressed about a nightmare she had in which she was unable to protect her own little girl from being abused. The therapist tentatively suggested, “That little girl in the dream sounds a lot like you.” Because she had never disclosed details of the abuse or the painful feelings it generated, this was a marker for sequential processing of a specific episodic memory of the abuse. Rachel was asked first to recall the context. CLIENT:

We are in the basement. I remember it always smelled musty. I wanted to go outside, but he is wanting to stay there . . . then he starts touching me [crying].

THERAPIST:

I know it’s hard to go there, but stay with it if you can. So, you are in the basement, 6  years old, and here is this grown man, Roger, touching you in sexual ways. What else do you remember? [continues to evoke concrete, specific, personal, episodic memories]

CLIENT:

I can smell his aftershave . . . gak!

THERAPIST: Stay with “gak”—like disgust? [directs attention to adaptive pro-

test, helps the client accurately label her feelings.] CLIENT:

Yes, disgust; it makes me sick just thinking about it. But I didn’t say no or tell him to stop; I went along with it [voice breaking, crying].

THERAPIST:

Okay, stay with that: He is touching you, and for some reason, you go along with it. Say more. . . . [promotes exploration of maladaptive self-blame]

CLIENT:

At first, I liked the attention, but after a while, I didn’t like it; I dreaded going over there. I begged my mother not to send me over there again, but she never listened; she was probably too busy with her new boyfriend. . . .

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THERAPIST:

So, he gave you the attention you needed and craved, but you didn’t want the sexual part? Dreaded it, in fact. And asked for help, but no one listened [focuses on unmet needs and healthy protest].

CLIENT: [under her breath, softly] Yes. THERAPIST:

What are you feeling? [empathic attunement to a shift in the client’s internal experience]

CLIENT:

Angry. I’m very angry at him.

THERAPIST: Yes, you should be very angry at him [provides validation and

support]. Can you imagine him over there? [pointing to an empty chair] What would you like to say, now, from your adult perspective? Here, the therapist initiates IC to heighten arousal and promote assertive expression of adaptive anger. The client expresses anger at being used and abused, which quickly shifts to sadness for her lack of protection. THERAPIST:

Okay, yes, so sad for that little girl; say more [pulling the empty chair closer, stroking seat of chair]. Can you imagine her here, little Rachel? How does she feel—afraid, alone? [empathic responding and guidance to promote self-compassion and self-soothing]

CLIENT: Dirty! THERAPIST:

Ah, dirty, like there’s something wrong with her. So unfair that this innocent little girl, you, Rachel, feels like there is something wrong with her. What do you think she needs to hear? [stroking seat of chair]

Here, the client expresses sorrow and compassion toward herself (“It wasn’t your fault. I wish I could give you back all that lost innocence”), and the therapist helps her experience the positive impact of that self-soothing. Later in processing the experience, Rachel connects the abuse to her lifelong pattern of hiding and pleasing others and vows not to hide and protect the perpetrator anymore. Rachel decides she wants to tell her mother about the sexual abuse, and she and the therapist agree to focus on this in future sessions. In another example, the client Serena experienced profound parental neglect as a child. She left home at age 13, became involved in drugs and crime, and lived for several years with a violent partner. Although Serena had since gotten her life on track, intense anxiety was activated in her current relationship with her rebellious teenage daughter. Serena connected this to herself as a teenager. She felt anxious for her daughter’s well-being but also self-rejection, the sense of herself as “rotten to the core.” She was still unable to forgive herself for teenage transgressions. The therapist asked if she had a specific memory of herself as a teenager. Serena recalled seeing herself in a mirror

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after one incident in which she had been badly beaten up. She described herself as being overweight with bad skin. THERAPIST:

What is the look on her face?

CLIENT:

Blank; she’s kind of out of it.

THERAPIST: What were you feeling as you looked at yourself—do you

remember? CLIENT:

I was disgusted with myself but also sad, hopeless.

THERAPIST:

How do you feel toward her now, you, that sad, hopeless teenage girl? [focus on adaptive emotion]

CLIENT:

I feel bad for her but, somehow, I still don’t like her.

THERAPIST:

Say that to her—“I reject you” [evocative empathy to heighten awareness of maladaptive self-loathing].

The client complied with the therapist’s directive and felt bad saying that and said she wanted to forgive herself, but she could not. The therapist asked her what gets in the way of forgiveness: “What stops you?” CLIENT:

She should have gotten herself out of that situation; there were options.

THERAPIST:

It’s like she chose to stay; that’s her crime.

This evocative empathy was intended to increase the client’s awareness of her perspective and leave the door open for further exploration. They agreed to continue the following session. In the following session, the client reported reflecting on the session during the week and, for the first time, remembering herself trying to get out of the situation—her desperation and sense of hopelessness. The therapist again asked Serena to recall herself as that teenage girl and express her feelings toward her. Serena responded, “I feel so sorry for you; you did not deserve all that suffering. Some adult—your mother, brother, Children’s Aid, anyone— definitely should have intervened. It was too much for you to do on your own at such a young age. They let you down, big time!” Serena was able to express forgiveness toward herself. This is an example of how memory evocation in therapy opened the emotion scheme and accessed new information for examination to promote change.

SUMMARY, CONSIDERATIONS, AND CAUTIONS In sum, reexperiencing trauma memories in EFTT is introduced at specific in-session markers and processing difficulties and has associated specific intervention goals. Critical steps in the process include promoting storytelling that is specific, personal, affective, and sensorial; activating the client’s core

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maladaptive sense of self developed at the time of the traumatic event; and accessing new adaptive emotions and self-protective capacities to change the maladaptive emotion scheme. The final step is shifting to IC of perpetrators using IC or EE and/or expressing soothing and compassion toward the self as a child. How Much Detail Is Necessary? The general guideline in EFTT is to access as much detail of the event as will activate the core maladaptive emotion scheme. This is particularly relevant, for example, in cultures where disclosing sexual abuse is prohibited. The clients described in the previous sections spontaneously described details of sexual molestation. The therapist did not explicitly ask for these details. In instances where clients are reluctant to disclose details, therapists need to validate and explore the reluctance and reassure the client that they have control over the process. If undisclosed aspects of the event or secrets continue to haunt the client, further disclosure and processing are required. This is a process of gradual engagement or exposure. Physical Pain It is not considered productive to have clients vividly recall the experience of physical pain associated with past physical or sexual abuse. Appropriate intervention involves helping clients find ways to explicitly bypass the physical pain to get at emotional pain and the maladaptive sense of self and other formed at the time. For example, a client described a scene of her mother hitting her with a vacuum cleaner: “What was so painful was the look on her face, knowing that my own mother wanted to hurt me.” Another client was highly distressed, recalling the physical pain of being raped by her father. The therapist helped her with physical grounding in the present and refocused her attention on any words her father said and thoughts she may have had at the time. She recalled her father warning her not to tell her mother and thinking she must be bad and him saying, “This is what fathers do to their little girls,” and her confusion. Intervention then focused on accessing protest—“Fathers do NOT do this!”—from her adult perspective. Dissociation Clients with a history of dissociation in response to trauma are at risk for dissociation in response to emotional arousal and trauma reexperiencing in therapy. This is a learned way of distancing the self from pain. EFTT intervention for dissociation includes standard procedures for physical grounding in the here and now, including looking at the therapist’s face, then exploring the shutting-down process in the moment, beginning with process observation to identify triggers (e.g., “I noticed that as soon as you started feeling angry,

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that’s when you kind of shut down—is that correct?”) It is essential to provide validation of dissociation as a learned self-protective response and emotion coaching about the value and role of adaptive (albeit painful) emotional experience. This is followed by collaboration on the process of gradual engagement (e.g., “to slowly help you tolerate and make sense of those painful feelings, so that you can heal, no longer alone, no longer a helpless child”). Dissociative identity disorder is a phenomenon that has received considerable attention in the trauma literature. From an EFTT perspective, this can be thought of as a disorder of narrative processing, in which clients use the notion of multiple identities as a framework for understanding their own dissociative experiences. Therapists need to be careful not to reify different client identities but rather to continually address the individual as a whole person. For example, under no circumstance should chair work (Chapters 6 and 9) be used to facilitate conversation between otherwise isolated “identities.” As in addressing dissociation, described earlier, therapists need to help downregulate clients who are too overwhelmed to cope with the content they are recalling. The following two chapters focus on other Phase 2 interventions to address fear and shame-related experience that interfere with engagement in key therapeutic tasks and, therefore, with resolving complex trauma.

8 Reducing Fear, Anxiety, and Avoidance of Internal Experience

R

eexperiencing and memory work described in the preceding chapter are intended to restructure a core sense of self related to fear and shame developed through traumatic experiences. This pervasive sense of self as worthless or insecure is automatically activated, much like overgeneralized trauma fear responses, as a holistic response to current interpersonal situations that resemble past trauma. This chapter, however, focuses on reducing discrete maladaptive emotions of fear and anxiety that are secondary to underlying thoughts and feelings. These secondary reactions are a major type of emotion (see Chapter 3) that is frequently observed in complex trauma. Working with these types of emotion requires interventions described in this chapter that specifically focus on the obvious and observable underlying cognitive–affective processes. The chapter that follows this one focuses on similar underlying processes related to guilt and shame. Fear and anxiety frequently result in avoidance or distancing the self from trauma feelings and memories, which, in turn, interfere with in-session processing and recovery from trauma. Thus, interventions described in this chapter also are aimed at helping clients to allow, explore, and thus make sense of previously avoided emotional experience. This is different from simply admitting to or labeling one’s feelings, although those are necessary first steps. Many clients can name their feelings yet do not allow themselves to feel the depth or intensity of those experiences fully. The distinction between admitting feelings and fully allowing their experiential impact was evident in the study described in Chapter  6 on the imaginal confrontation https://doi.org/10.1037/0000336-009 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  181

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(IC) procedure that asked clients to identify the most helpful aspects of emotionfocused therapy for trauma (EFTT; Holowaty & Paivio, 2012). The aspect clients most frequently identified as helpful was fully allowing painful and threatening feelings and deeply experiencing, for the first time, the damaging impact of childhood abuse and neglect. In this chapter, we compare EFTT with other approaches to working with secondary fear-related experience, provide clinical guidelines for distinguishing among the different types of fear observed in trauma therapy, and specify the relevant change processes and goals. In the last half of this chapter, we specify different types of observed experiential avoidance and appropriate intervention for each. These include step-by-step guidelines for helping clients allow emotional pain and a general model of steps to reduce fear and avoidance of internal experience. This model also applies to reducing self-critical processes presented in the chapter that follows.

PERSPECTIVES ON FEAR, ANXIETY, AND AVOIDANCE: EFTT COMPARED WITH OTHER APPROACHES As noted throughout this book, fear, anxiety, and the associated avoidance of trauma-related internal experience are defining features of posttraumatic stress disorder (PTSD) and complex traumatic stress disorders. It also is universally recognized that such avoidance perpetuates disturbance. Thus, helping clients to allow and accept trauma feelings and memories rather than avoid them is an essential ingredient of all successful trauma therapies. For example, dialectical behavior therapy (DBT; Linehan, 1993) for borderline personality disorder (which is strongly associated with a history of child abuse trauma) balances a focus on changing destructive behaviors (e.g., self-harm, substance abuse) with “radical acceptance” of self and validation of the client’s feelings and perceptions. DBT also teaches mindfulness meditation techniques to help clients observe and accept the flow of thoughts and feelings rather than react to or try to change them. Recent cognitive therapy for depression (Segal et al., 2013) and acceptance and commitment therapy (e.g., Hayes et al., 2012) similarly emphasize acceptance of distressing internal experience. The promotion of presentcentered awareness and nonjudgmental acceptance of internal experience are part and parcel of EFTT. However, although EFTT may incorporate skills training for severe emotion dysregulation, it relies more on therapist empathy to help reduce client distress and focuses more on meaning exploration rather than simple observation and acceptance of internal experience. EFTT also shares features with contemporary psychodynamic approaches to trauma, such as affect phobia therapy (McCullough et al., 2003), that focus on the defensive covering of core affective experience, except that confrontation and interpretation of defensive processes are not part of the EFTT repertoire. Of these psychodynamic approaches, attachment-based models, such as accelerated experiential dynamic psychotherapy (Fosha, 2021) and mentalization approaches (Levy et  al., 2006), are the most compatible with our approach.

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Thus, the common ground would emphasize the provision of a secure attachment bond and empathic responsiveness to a client’s feelings and to reduce defensive avoidance and access core affect. Effective trauma therapies described in the preceding chapter also focus specifically on changing the dysfunctional beliefs associated with PTSD and complex PTSD. These include catastrophic expectations about and avoidance of external situations and internal experience. Cognitive behavioral inter­ ventions typically involve psychoeducation and Socratic questioning to challenge such dysfunctional beliefs. However, EFTT interventions, such as gestaltderived two-chair dialogues, are intended to (a) increase clients’ awareness of how their thoughts and feelings contribute to maladaptive fear, anxiety, and avoidance and (b) allow clients to deeply experience, in session, the discomfort of these emotional processes. Such deep experience of discomfort (c) activates alternative healthy internal resources (adaptive thoughts, feelings, needs) to counteract these maladaptive processes and helps clients allow disavowed painful experience. Processes like this for allowing emotional pain are described later in this chapter.

PROCESS DIAGNOSIS: DISTINGUISHING DIFFERENT TYPES OF FEAR AND ANXIETY Appropriate intervention in EFTT requires an accurate process diagnosis of different types of fear and anxiety and their associated processing difficulties, according to the typology presented in Chapter 3. These emotion types are described in the subsections that follow. Adaptive Fear and Anxiety Although fear and anxiety are frequently considered synonymous, they have distinct properties and functions that have implications for therapeutic intervention, as outlined next. Fear As a basic emotion, fear is automatically activated in response to a perceived imminent threat of harm and is associated with the action tendencies of fight, flight, or freeze (shut down, play dead) to escape or avoid the danger. Traumarelated problems with this type of adaptive fear concern lack of awareness and concomitant lack of appropriate self-protective response. For example, among child abuse survivors, vulnerability to revictimization is thought to stem, in part, from an inability to recognize or trust one’s perceptions concerning danger (Courtois et al., 2020). Anxiety Anxiety is distinct from fear in that it involves anticipating a potentially harmful or threatening situation rather than being confronted with imminent danger.

184  Emotion-Focused Therapy for Complex Trauma

In moderation, anxiety can be adaptive by motivating strategies for coping with an anticipated danger, as in seeking help to avoid an episode of domestic violence. Although its inherent meaning is not a source of difficulty per se, problems with adaptive anxiety occur when it is of high intensity. When this happens, it interferes with information processing, learning, and ultimately, the ability to respond adaptively to the threat. Problematic Fear and Anxiety Problems with maladaptive fear and anxiety are easily recognized by therapists and clients alike. Again, distinguishing among different types of these emotions is crucial to effective intervention. Primary Maladaptive Fear Primary maladaptive fear is an automatically activated and conditioned response to stimuli that have become associated with harm. This is the type of fear classically observed in PTSD reactions. For instance, a refugee from a country with a violent military may experience feelings of terror and panic at the sight of anyone in a uniform. Depending on the individual, this terror may result in rage and aggressive behavior, fleeing the situation, or paralysis. Over time, this fear response can generalize to other stimuli and situations—underregulated anger, avoiding situations, chronic hypervigilance, and overcontrol. From a neurological perspective, this represents a narrowed “window of tolerance” (Porges & Dana, 2018), such that the individual is increasingly reactive to more and more neutral stimuli. The problem here is an overgeneralized fear and avoidance of situations that, in fact, are harmless. A Core Sense of Self as Vulnerable or Insecure A core sense of self as vulnerable or insecure is a kind of hybrid of primary maladaptive fear or anxiety that is the focus of trauma reexperiencing and memory work described in the preceding chapter. This sense of self is organized around experiences of fear, dread, and chronic anticipation of danger that originated in attachment relationships and is activated in current interpersonal situations. This pervasive sense of vulnerability is activated as a holistic experience. Although anticipating danger and having catastrophic expectations are both part of this complex self-organization and perpetuate feelings of anxiety, those cognitive processes do not precede or generate its activation. In this sense, the experience of vulnerability is distinct from secondary anxiety, and this distinction has implications for differential intervention. The problem here is that the activation of an insecure or vulnerable sense of self makes people feel fragile, powerless, or victimized and interferes with self-confidence, coping, and the capacity for interpersonal relatedness. People can be hypervigilant, emotionally overcontrolled, and distrusting of others, especially intimate others. However, some individuals also can be chronically angry, keeping others at a distance.

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Another important point is that complex trauma in attachment relationships typically results in both chronic insecurity and feelings of worthlessness and inferiority. Thus, the sense of self is typically organized around experiences of both fear and shame. Although traumatic experiences of fear on the one hand and shame and self-blame on the other may coexist for an individual, one of these usually dominates as a more salient way of being in the world. Interventions need to target the dominant experience. However, clients dealing with complex trauma will typically suffer the effects of secondary anxiety and avoidance in their efforts to skirt the deeper primary feelings. Maladaptive Anxiety Maladaptive anxiety is most often defined as a secondary emotional experience because it is preceded and strongly influenced by obvious maladaptive beliefs. These anxiety problems can entail the misattribution of danger and lead to inappropriate avoidance. Anxiety also can be secondary to other painful or threatening feelings, such as anger, neediness, embarrassment, or shame. Traumatized individuals, for example, experience anxiety about the emergence of feelings, memories, and bodily sensations associated with the trauma (resembling the anticipatory anxiety associated with panic disorder). This is the basis for the avoidance symptoms so characteristic of PTSD. The problem here is that maladaptive anxiety and the subsequent avoidance of trauma material interfere with processing and change. Thus, chronic anxiety needs to be reduced, and the meaning of any underlying emotions needs to be explored. Complex Maladaptive Emotion Versus Emotional Pain In addition to the different types of fear and anxiety described earlier, emotionfocused therapy has distinguished between complex “bad feelings” and “emotional pain” (Greenberg & Paivio, 1997; Pascual-Leone & Greenberg, 2007). These types of experiences are uncomfortable, and people make efforts not to feel them or try to get rid of them. However, for change to occur, they both need to be experienced in session. Even so, they involve different change processes and call for different intervention strategies. Complex Maladaptive Emotion Feelings of hopelessness, helplessness, desperation, or despair are common among victims of complex trauma. These are complex secondary emotional reactions or products of the activations of core maladaptive emotion schemes or self-organizations. These can be vague feelings causing global distress that need to be regulated, explored, and differentiated, and the underlying issues related to a maladaptive sense of self need to be addressed. In general, changing bad feelings and global distress of this kind involves complex processes that correspond to those outlined earlier in the general model of change and illustrated in Figure 3.1. This includes exploring the cognitive–affective constituents (e.g., shame, sense of self as intrinsically unlovable, fear of others as rejecting, and belief in the inevitability of abandonment) that generate the bad feeling

186  Emotion-Focused Therapy for Complex Trauma

and then accessing adaptive emotions and associated healthy resources so that this information can be used to modify the underlying maladaptive emotion scheme. Emotional Pain Complex relational trauma also involves intensely painful emotional experiences related to feeling unwanted, unloved, worthless, or inferior or stemming from the loss of cherished aspects of the self or the loss of or separation from loved ones. This kind of feeling is not “global” in the sense of undifferentiated distress but rather a primary adaptive experience of emotional pain, an overarching embodied assessment of the casualties that have and are being endured. As such, emotional pain differs from basic feelings such as anger or sadness in that it is more complex than any single emotion (Greenberg & Paivio, 1997). This type of emotional pain needs to be allowed to (a) incrementally engage the previously thwarted feeling, (b) acknowledge that damage to the self has occurred, and (c) understand the precise nature of the damage or harm. Only after facing this damage can one integrate this information about the self. Over time, this process of acceptance will lead to a redefinition of the self and the development of new values, concerns, and coping strategies to heal the damage.

CHANGE PROCESSES AND GOALS The overarching objectives for addressing fear, anxiety, and experiential avoidance in EFTT emerge from steps in the general model of change presented in Figure 3.1 (Pascual-Leone, 2018). These are to (a) access the underlying maladaptive emotion structure or scheme (i.e., fear, shame); (b) explore the related cognitive, affective, and motivational constituents; (c) support the emergence of other adaptive emotions and associated healthy resources; and (d) use these to modify or transform the maladaptive emotion structure. Of course, at each of these steps, various forms of avoidance may continue to interrupt progress through later steps in the model and block the process of change. So, although all the interventions presented next follow the general model, they address specific blocks that may occur at specific steps in the change process. Addressing problems of underregulated fear and anxiety begins, by necessity, in the first session. However, explicit therapeutic work to reduce fear and anxiety and experiential avoidance generally begins only after a therapist repeatedly observes these processes in session and there have been unsuccessful attempts to bypass the problem. Sometimes the problem can be bypassed, for example, by the therapist’s calming response (e.g., “Just breathe—easy. That’s right; it’s going to be okay”) and invitations to allow threatening experience (e.g., “I know you want to push it away, that sense of being unlovable, but would it be okay to just get closer to that experience”), directing attention to

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the suppressed experience (e.g., “So painful. Stay with that; tell me more”), or through use of evocative empathic responses to increase arousal and access it (e.g., “So scary—all alone with all those painful feelings!”). Although EFTT focuses on reducing the fear and avoidance of both external and internal stimuli, it particularly promotes acceptance of internal experience. This approach to therapy fosters a desire to know, respect, nurture, and protect rather than reject or disavow the part of the self that has been injured. For example, the therapist might say, “It’s important what you’ve been through, Paul— a profoundly meaningful part of who you are. I want you to learn to embrace and respect that part of yourself rather than pretending to be someone you are not.” The following intervention principles identified in the general model of emotion-focused therapy (Greenberg & Paivio, 1997) are particularly relevant to work with trauma-related fear. We begin with identifying processes and goals related to the task of managing fear and anxiety, which is a prerequisite for other tasks. Many of these resemble the strategies used in other treatment approaches. Gradual Engagement The principle of gradual engagement is synonymous with the traditional construct of gradual exposure, except that it explicitly recognizes and prizes the agency of the client. As discussed in previous chapters, gradual exposure begins with the disclosure of traumatic experiences in early sessions before later in-depth reexperiencing, initially working with less threatening others in the IC procedure or expressing feelings to the therapist. Therapists can also begin by deliberately using less evocative language to access threatening feelings, such as anger (e.g., “You didn’t like” as opposed to “You hated”). This is the construct of successive approximations to the threatening feelings. As a rule, clients decide in what manner and how often they confront trauma material. Emotion Regulation of Overwhelming Feelings Although the therapeutic relationship is the primary vehicle for emotion regulation in EFTT, therapy can also use well-recognized emotion regulation and distress tolerance strategies, such as physical grounding, distraction, or gentle self-talk (e.g., Linehan, 2015; Najavits, 2002), as well as mindfulness-based practices (Kabat-Zinn, 1990). These skills are typically integrated through experiential “hot” learning in the context of aroused feelings in the momentby-moment process of the session, as opposed to “cool” learning in an instructional or tutorial context (Greenberg & Paivio, 1997). Whether by way of the relationship or emotion regulation skills, or both, the goal is to help the client manage distress and gradually approach the feared experience (e.g., the therapist might say, “It’s okay. Breathe. That’s good. Can you tell me what’s so difficult?”). During this process, the therapist functions as a secure attachment

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figure, like a soothing parent with a frightened child or serving a similar role as a supportive spouse in emotion-focused therapy for traumatized couples (S. Johnson, 2002). Allowing and Owning Painful Experience The important aspect of allowing previously disavowed painful experience is the experiential linking of information to the self-narrative. This is the first step toward motivating new ways of being and new resources. For example, Claire (presented in the preceding chapter), whose parents minimized sexual abuse by her brother, eventually accessed intensely painful feelings during the IC procedure (“I feel dirty!”), which quickly shifted to sadness at her loss of innocence and self-respect. The therapist empathically responded to her vulnerability and encouraged Claire to imagine herself in the empty chair and express what she needed as a little girl. This compassion for herself and selfsoothing quickly shifted to anger at her brother, both of which were new adaptive experiences to help promote healing. Facing Adaptive Hopelessness Accepting irrevocable loss or damage and the futility of attempts to change circumstances or others is essential to letting go of past traumas, healing, and moving on. Clients need to face the fact that no matter how hard they try, they cannot get back what was lost or get an abusive parent or spouse to change, love them, apologize, acknowledge responsibility, or feel remorse. If one gives up struggling against the irrevocable truth, stops “wishing it were not true,” and accepts realistic hopelessness or defeat, this will lead to giving up un­­attainable goals or unworkable strategies. This is the principle embodied in the Alcoholics Anonymous Serenity Prayer and the Buddhist and mindfulness principles of nonattachment. Peace and serenity can be attained by accepting life on life’s terms and focusing one’s energy on working with what is. The goal of EFTT interventions, therefore, is to increase client reflection on this (e.g., the therapist might ask a client, “What’s it like to know that you can push, push, push and still not get what you want—desperately hoping that one day he will see the truth?”) and their acceptance of the reality of hopeless situations. Acceptance, in this case, must be differentiated from depressive resignation. We return to this topic in Chapter 11 in the context of sadness and grief. Symbolization Verbal symbolization reduces anxiety because it helps clients make sense of traumatic experiences and gain a sense of control. The capacity to communicate deeply painful experiences to others also reduces the sense of isolation characteristic of PTSD. The goal of intervention is to help clients articulate not only specific feelings but also the meaning of the feelings and the internal

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processes that contribute to the experience. For example, the therapist might ask, “What was so hurtful about that for you? I know in a general sense, but it’s important to say what exactly was so bad for you.” This shift in focus from the general case to that which is particular to the individual is the essence of promoting experiencing. Promoting Agency The most common action tendency of fear and anxiety is to withdraw from further engagement. Whether adaptive or maladaptive within a particular circumstance, emotional and behavioral avoidance is not typically experienced as an act of personal agency. One client said candidly, “I feel like I’ve been running away from this all my life.” The experience of personal agency can serve as an antidote to fear and anxiety, where instead of experiencing themselves as reacting in fear, clients come to recognize themselves as active participants in contributing to these experiences. Increasing clients’ awareness of how they contribute to their own anxiety is necessary for emotion regulation and permanent change. The goal is to help them recognize that it is “I” who is thinking, feeling, needing, wanting, or doing this. If clients experience themselves as generating their feelings, they begin to see how they can change them. Process observations such as “It’s as if you have taken over where your parents left off” are in the interest of promoting client awareness of personal agency (for better or for worse) rather than blaming. Again, EFTT interventions promote the “hot” experiential awareness of agency as processes emerge in session. This is particularly relevant in two-chair dialogues and is discussed further in a later section of this chapter.

INTERVENTIONS FOR MANAGING ANXIETY AND FEAR In the face of evoked trauma material, obvious in-session indicators of underregulated fear and anxiety include panic, dissociation, catastrophic expectations about current situations or internal experiences, or overgeneralized fear in current situations. Management and emotion regulation are necessary to promote exploration and understanding, which is the primary focus of EFTT. An example is the client Monica who felt panicky remembering the events following her mother’s suicide. In her life, she was unable to attend funerals because of crippling anxiety and dreaded the anniversaries of her mother’s death. Client responses such as these are addressed through reexperiencing and repeated imaginal exposure, sometimes in the context of the IC procedure or in conjunction with two-chair enactments (described later). When necessary, EFTT also uses standard skills training interventions to manage fear and anxiety and achieve appropriate distance from potentially overwhelming emotions (e.g., Linehan, 2015). These include grounding strategies to help

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clients focus on the present reality of their body (e.g., bum on the chair, feet on the floor), regulated belly breathing, muscle relaxation, or distraction to help them focus on details of the external environment (e.g., the color of people’s clothes when walking down the street) rather than on thoughts that escalate anxiety. To address dissociation, intervention additionally involves processing the experience and providing education about the function of dissociation. The longer term goal is to strengthen the self so that the client can handle a feared experience (e.g., the therapist might say, “We want you to no longer feel like that defenseless little girl, so you don’t have to disappear or go away like that”), which also involves developing more adaptive emotion regulation strategies. This is followed by gradual engagement with threatening material. Therapists should not persist with the IC of the perpetrator if, in fact, the perpetrator was the stimulus for dissociation. For example, one client psychologically escaped during sexual molestation by imagining herself as a “little angel” far removed from the experience. In our view, she would be unable to let this dissociative part of herself go until she felt strong enough to face those feelings and memories. Successful interventions involved brief confrontations of the perpetrator during IC and accessing and validating her disgust and anger toward him in efforts to strengthen the self. The intervention also included two-chair dialogues between the terrified (and disgusted) little girl and the little angel parts of herself. These strategies finally ended with an imaginary dialogue in which the client thanked the little angel for having protected her all these years and then said goodbye to her, releasing her from that outmoded way of coping. The processes of reducing avoidance and accessing self-soothing in EFTT are intimately connected. If we are to ask clients to allow their most frightening and painful experiences, we must ensure they have the capacity to comfort themselves. This capacity frequently was not developed in insecure attachment relationships. Self-soothing skills, therefore, are taught, shaped, and encouraged in EFTT. It can be particularly helpful to ask clients to imagine what they needed as children when they were afraid or how they would comfort their child or a friend and then apply this to themselves as adults (i.e., the frightened child within). Interventions to promote self-soothing are presented in the following chapter on shame. As with all processes, effective intervention to reduce client avoidance of internal experience involves an accurate process diagnosis. The following section specifies the types of experiential avoidance typically observed in EFTT and corresponding intervention strategies. Different Types of Avoidance We define experiential avoidance broadly as any internal process (distinct from maladaptive behavior such as substance use) that interferes with clients’ capacity to access and express the full range of emotion, particularly adaptive

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emotion. In general, we distinguish between unconscious and conscious processes. Unconscious avoidance processes are observed in some types of lowlevel experiencing, described in Chapter 5. These difficulties accessing internal experience are attributable to skills deficits or learned maladaptive strategies for coping with distress. The difficulties developed through insecure attachment, which did not provide children with the freedom to attend to and explore their own internal experience. In abusive and neglectful environments, children learn to be externally focused and hypervigilant for signs of danger, or they learn that their feelings and perceptions are ignored, not valued, or overtly punished. This externally oriented processing style is evident in clients’ narrative quality. As described in the preceding chapter on memory work, their storytelling may be externally focused and devoid of emotion (empty story), overly rational and intellectual, or vague and overgeneral or incoherent. The client might also have a limited emotion repertoire, evident in secondary or defensive emotions that preclude exploring more primary experience—for example, chronic anger covering fear or sadness. These clients typically require deliberate emotion coaching in the form of psychoeducation, direction, and guidance, as described in Chapter 5 in the section on deepening low-level experiencing, before they can begin to approach and allow emotional experience. This process requires patience and persistence over several sessions to gradually deepen experiencing. Secondary Emotions Covering Adaptive Emotions One form of avoidance consists of a simple sequence in which a primary emotion is quickly followed by another emotion that functions to regulate, distance, or protect the individual from the initial experience. In psychodynamic terms, these are considered defensive emotions. This process can be either conscious and deliberate or unconscious, and the client is unaware of the underlying emotion. In these cases, where one emotion is dominant, clients usually have a limited emotional repertoire. Markers of secondary defensive emotions are evident when the client repeatedly expresses, for example, hurt, sadness, or fear concerning maltreatment but seems to have no access to anger. Alternatively, the client has been deeply hurt but only expresses anger. There may be brief and subtle verbal or nonverbal indicators of the underlying emotion, but this quickly disappears. More complex sequences include the client experiencing primary shame, then expressing secondary anger at being humiliated, followed by feeling guilty or anxious about their anger. All these sequences that involve secondary emotion are typically also mired in global distress because secondary emotion usually also lacks the same depth of specificity of meaning that one finds in primary emotion. At markers of secondary emotion covering more primary emotion, the therapist can invite clients to examine what they are feeling (e.g., “Something about her rejection made you feel angry?”). This can open an opportunity to help the client access primary experience—in this case, hurt. Frequently,

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however, intervention also requires the therapist to make explicit process observations and discussions with clients about how a specific experience seems to dominate their repertoire and possibly serves some protective (i.e., defensive) function. This can be accompanied by providing psychoeducation about normal emotional processes—distinguishing between adaptive and maladaptive emotion, for example—and collaborating on the goal of expanding clients’ emotion repertoire. For example, a client had a history of anger control problems, and anger dominated his emotional experience. During one session, he expressed anger at his wife for using his abuse as a child against him in arguments. Helpful interventions validated his anger at betrayal and directed his attention to more vulnerable experience (the therapist said, “I hear how angry you are. And at the same time, it must be so hurtful to have her take your trust and use it against you like that”). He then was able to acknowledge that he felt like his wife probably did not love him. This opened the door to exploring how his anger had pushed others away and deprived him of the connection and love he wanted. The therapist used empathic responses to evoke and support his sadness, loneliness, and longing for connection and love (e.g., “So, under all that anger is a sad and lonely man, hungry for love and yet pushing others away for fear of being hurt”). Over the course of several sessions, the client was able to acknowledge his more vulnerable experience and receive comfort and support from the therapist. Interventions also validated his need to protect himself and addressed how he could feel safe while expressing vulnerability outside of the session. Conscious and Deliberate Suppression Conscious suppression of emotion is readily observed in therapy sessions as clients approach painful or threatening feelings and deliberately pull back. Markers include explicit statements (e.g., “I don’t want to cry”), nonverbal self-interruption of emerging experience (e.g., tears well up, and the client deliberately suppresses them), or minimization of pain or harm (e.g., “It could be worse,” “My parents tried their best”). From a narrative perspective, this type of client storytelling involves “competing plotlines” (Angus et al., 2019; Paivio & Angus, 2017), indicating an internal conflict between maladaptive suppression and adaptive, although painful, emotional experience. The overall task, described in the following section, is to help clients allow emotional pain.

HELPING CLIENTS ALLOW PRIMARY EMOTIONAL EXPERIENCE When painful but adaptive emotion is consciously suppressed or overcontrolled, the change process involves helping clients allow this avoided material to access its adaptive information.

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Addressing Difficulties With Allowing Painful Emotion The pain of rejection or loss can feel like it will destroy oneself and thus may be avoided as a deliberate self-protective strategy. Approaching painful emotion requires gradually overcoming the fear of falling apart or being destroyed by it, followed by a conscious decision to allow and engage it. Activating the pain-producing emotion structure through gradual engagement (exposure) modifies a client’s belief that they cannot handle the pain, which is then followed by meaning reconstruction. The process of allowing emotional pain in emotion-focused therapy has been studied using analyses of videotaped therapy sessions and clients’ descriptions of their experience of allowing previously avoided painful material (Bolger, 1999; Greenberg & Bolger, 2001). Convergence of these findings resulted in the four-phase process outlined next. It should be clear that this is a metatask that, like EFTT itself, may unfold over many sessions and may incorporate and be embedded in other interventions and tasks. Approaching In the first phase, previously avoided experience is approached and discussed. For example, after several sessions, a client, “John,” was encouraged to describe in detail the events surrounding the drug overdose and death of his mother (see the preceding chapter on memory work)—coming home from school and seeing the ambulance and police around his house. Interventions that facilitated the client approaching such painful material included highlighting his strengths, resources, and resilience throughout the therapy process and using emotion regulation strategies. Therapists, above all, need to communicate compassion for their client’s pain and validate how hard it is to approach these feelings (e.g., “It’s terrible for a child to feel so alone and afraid. I know it must be so hard to feel that again”). Therapists must also communicate the importance of owning these experiences as part of the self and provide support (e.g., “It’s okay, John, let it come. This is so important”). Allowing In the second phase, while reliving a traumatic experience, clients see and accept themselves as having been damaged by the trauma. This can be a threatening experience at first, as clients begin to appreciate the weight of their emotional pain. John saw himself as a defenseless little boy ripped away from his beloved mother when he was placed in an orphanage after her death. This step in the process involves a conscious decision on the part of a client to fully allow the pain of the experience, despite their fear. In this phase, one of the goals is to help clients tolerate the complex set of feelings and realizations that emerge in the process. For John, facing the pain of his mother’s death and the subsequent brutality and betrayal he experienced in the orphanage also involved facing his rage and the hopelessness and despair of knowing that he had never received the love and nurturing he needed. He also needed to face and accept his history of coping through substance abuse

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and the wasted years and loss of opportunity and forgive himself. Gradually and with time, therapists’ provision of comfort and empathic affirmation are internalized by the client. These internal resources, in turn, help establish stability in the face of what was previously overwhelming and provide access to a more self-affirming stance. Exploring In the third phase, questions and doubts about the newly acknowledged view of self open the door to self-exploration. This requires helping clients stay with feelings of being shattered, fully acknowledge the harm done to them, identify the cause of damage and the person(s) responsible, and allow the full expression of feelings of anger and sadness about traumatic events. This can be a time to introduce or reintroduce IC or evocative exploration (EE). The IC with another client, “Martha,” began with expressions of anger toward her husband, who had abandoned her and her four children 30 years earlier (“I hate you. How could anyone be so heartless?”). This activated a shift into deep sobbing and fully experiencing the pain of her sadness and loss for the first time. The therapist’s soothing responses (e.g., “So many tears. Let it come”) helped Martha sink into her vulnerability and weep for her suffering. This process also accessed questions about herself that later could be explored: CLIENT:

How could I have put up with his crap for so long?!? Was I so desperate?

THERAPIST: So, you were willing to accept anything he threw your way,

desperate for . . .? CLIENT:

His love, I guess. But he never loved me—was always putting me down or going off by himself. I just didn’t want to see it.

THERAPIST:

Didn’t want to face the truth; it was too . . .?

CLIENT:

Devastating. I didn’t think I could survive, literally. I felt like I might not survive.

THERAPIST:

Like your very life depended on him.

This exploration led to a shift in Martha’s view of herself from a vulnerable and victimized young mother to a mature woman who had survived and raised her four children on her own. Integrating In the fourth and last phase of this process, the painful experience is accepted and integrated into the sense of self. Clients have a clearer view of themselves and how these experiences functioned in their lives. They can clearly express feelings associated with damaging people and events and possibly take responsibility for contributing to their own pain (e.g., “My anger has pushed others away”). Therapist responses that support this new sense of self (e.g., “It’s like

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your entire life has been defined by that moment—abandoned, terrified, and alone”) facilitate an increased sense of personal agency and control rather than victimization. Fully allowing experience also mobilizes the associated needs that challenge maladaptive beliefs associated with the painful state. Knowing one’s wants and needs empowers the individual to assert boundaries or seek out support, either internally, in the form of compassion and self-soothing, or interpersonally, from the therapist or others. According to Bolger (1999), this is the process of recognizing “covers” or the maladaptive ways one has hereto avoided pain (e.g., through substance abuse, excessive work, control of others). Therapy can involve a separate process of helping clients gradually make different life choices to address this. Case Example: Reducing the Self-interruption of Emotion The client Angela (Paivio, 2013), who was exposed to extreme family violence in childhood, initially struggled between a desire to express her feelings—to be free and authentic—and be overcontrolled. The intervention aimed at helping her integrate her authentic emotional experience by allowing pain and accessing self-soothing resources. In the following excerpt, the therapist affirmed her vulnerability in approaching painful memories of herself as a child and validated the client’s struggle to suppress her feelings. At the same time, the therapist provided encouragement and support to help Angela relinquish overcontrol, as well as evocative empathy and process directives to activate her painful feelings related to unmet childhood needs. THERAPIST:

Is there a specific memory or event you would like to focus on?

CLIENT:

When I picture myself, it’s like just a little girl in a dungeon.

THERAPIST:

In a dungeon—that’s a very sad image.

CLIENT: [wipes tear, shrugs shoulders] There’s worse. [minimization] THERAPIST:

Yes, there’s worse, but it’s not a way you want your little girl to be raised, in a dungeon. [The client nods her head in agreement.] Can you speak from what it was like for you?

Here, Angela was obviously trying to suppress her tears. The therapist validated her struggle but focused on bypassing suppression and accessing the healthy side of self. She helped the client express her sadness by specifying all the things she missed out on as a child and empathically responding to those losses. THERAPIST:

I know it’s hard—you’re trying to hold back—but if you can try and get in touch with that little girl, Angela, in a dungeon. What is she feeling? Lonely?

CLIENT:

Helpless—you said it before.

THERAPIST:

Helpless, yes, totally helpless—just shut out and helpless and alone.

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CLIENT: [suppressing tears] I’m sorry; I don’t like to cry. THERAPIST:

I know you don’t want to cry, but . . . just a lot of tears for that little girl; she missed out on a lot. [The client silently weeps.] What did you miss the most, do you think?

CLIENT: [wiping tears] I think those happy childhood memories—you

know—that people talk about. THERAPIST:

Yes, children should be happy, carefree, and have all kinds of happy memories. You got cheated.

CLIENT:

My mom and dad, they tried [minimization].

THERAPIST:

They tried, and your strength is in understanding where they are coming from. But it doesn’t change the pain that you went through. It’s important.

CLIENT:

Yes. [wiping eyes with a tissue]

THERAPIST:

You missed out on some precious things.

Once Angela had allowed the pain of her childhood memories, even momentarily, she also accessed healthy anger and held her father responsible. The therapist’s empathic responses supported and encouraged this new assertive expression. In later sessions, Angela was encouraged to engage IC or EE with her imagined father to integrate this new perspective further. General Model of Resolving Intrapersonal Conflict Self-interruption is one type of intrapersonal or “self–self” conflict, along with catastrophic expectations, generating anxiety, which is discussed later. (Selfcriticism generating guilt or shame is discussed in the following chapter). When emotions are interrupted by client beliefs or injunctions against feelings (e.g., “Anger is a sin,” “Crying is feeling sorry for oneself”) and catastrophic expectations about emotional experience and expression (e.g., “If I start crying, I will never stop”; “If I get in touch with my anger, I will go crazy or hurt someone”; “If I get in touch with my anger, I will look like my father”), the first step is to provide accurate information about adaptive emotional experience, the negative consequences of suppression, and the process of recovery. Once clients are on board with the value of the task, the next step is to explore and understand the self-interruptive process. Importantly, the self-interruptive process needs to be explored in depth only if the emotional block seems impassable. The general rule of thumb is to bypass working with self-interruption and avoidance if it is possible to do so. If the client can be encouraged to express primary emotion with the support of validation and empathy alone (as was the case with the client Angela, described earlier), the intervention will not be needed. The overarching goal is to help the client accept the suppressed emotion, experience it in awareness, and express it. Subgoals are to (a) increase client

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awareness of how they interrupt their experience or contribute to their fear and anxiety (the thoughts and feelings involved), (b) increase client awareness of the negative experiential consequences of self-interruption, and (c) motivate a desire to allow the interrupted experience. Again, understanding how one’s thoughts and feelings contribute to one’s experience strengthens the self because it increases agency and control. Although the techniques differ, cognitive behavior therapy approaches, which many readers will be familiar with, also help clients understand the connection between their maladaptive beliefs and, for example, depression or anxiety. If clients do not understand the connection, they cannot change. The following general model presents the process of resolving the intra­ psychic conflict between a dominant, maladaptive part of self (suppressing, catastrophizing, criticizing) and the subdominant part of self that feels the effect of these maladaptive processes (squashed, afraid, guilty, or shamed). The traditional gestalt (Perls et  al., 1951) conceptualization of the conflict between the “top dog” (the dominant maladaptive part of self) and the “underdog” (the weaker experiencing part that has “no voice”) is a simplified but useful framework for understanding this intervention process. For our purposes here, we focus on the conflict between feelings that push for expression and the part of the self that squashes that experience. The therapist’s job here is to support the underdog, the healthy part of the self that is chronically squashed, and help that part have a voice. Chair work for intrapersonal conflict has been studied and refined to specify several distinct steps. Moreover, separate tasks have been formally created for resolving self-criticism, self-interruption, and anxiety (e.g., Elliott & Shahar, 2019; Watson & Greenberg, 2017; Watson et  al., 2019). We present here a general model (see Figure  8.1) that focuses on commonalities among these different tasks viewed as internal obstacles and, therefore, substeps in the larger task of resolving complex trauma. Many clients find it easier to engage in two-chair dialogues between parts of the self than to imaginarily confront perpetrators in the IC procedure. However, even when clients are unable to engage in two-chair work (e.g., because of performance anxiety), the general model can act as a guide to the intervention process, just as the model of resolution described in Chapter 6 guides the less stressful EE intervention. Figure 8.1 presents client processes and interactions between the dominant (top of Figure 8.1) and experiencing parts of self (bottom of Figure 8.1). The following sections describe therapist operations to promote those processes. The focus is on working with self-interruption, which is typically also accompanied by anxiety-producing messages (i.e., it is not safe to feel). As in IC, two-chair interventions involve a reiterative rather than linear process. A case example illustrating this process model follows. Collaborate on and Structure the Task Following a marker of intrapsychic conflict, the initial step involves identifying and separating the two sides of the self and establishing contact between them. In the case of the marker for self-interruption, the therapist observes

PHASE 1

MARKER • Self-criticism • Catastrophizing • Interruption of feeling

PHASE 2

SPECIFY negative message (content and quality)

INTENSIFY OR EXAGGERATE negative message

VALUES AND STANDARDS

SOFTENING • Understanding • Self-compassion • Openness to compromise NEGOTIATE relationship with self

EMOTIONAL REACTION • Ashamed • Afraid • Constricted

PAIN OR DISCOMFORT of shame, fear, constriction

HEALTHY PROTEST

NEEDS • Support • Confidence • Free expression

INTEGRATE new sense of self

Note. Adapted from Facilitating Emotional Change: The Moment-by-Moment Process (p. 193), by L. S. Greenberg, L. N. Rice, and R. K. Elliott, 1993, Guilford Press. Copyright 1993 by Guilford Press. Adapted with permission.

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FIGURE 8.1.  Model of Resolving Intrapersonal Conflict in Phase 2 of Emotion-Focused Therapy for Trauma

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some emerging experience and the client pulling back (e.g., “You got in touch with some anger there, but something happens—somehow it’s hard to stay with it”) and further observes that this process has occurred repeatedly in therapy (i.e., is not easily bypassed). The client recognizes this pattern, and they agree to engage in the two-chair procedure to understand better and eventually change the maladaptive pattern. Structuring the procedure resembles structuring the IC procedure, described in Chapter 6, except the client is enacting an internal dialogue between two parts of the self. We have found it most helpful for clients to sit in their usual chair when they are speaking from the healthy part of self that is being interrupted or suppressed. This helps them identify with that part of self throughout therapy. They will sit in the opposite chair when speaking from the dominant maladaptive suppressing part of the self. Articulate the Negative Message It is most naturalistic and effective to begin the dialogue with the client taking the role of the dominant part of the self (top of Figure 8.1). As in the early stage of IC, when the purpose of imagining the negative other is to evoke a response in the self, the purpose at this stage is to evoke a reaction in the part of self that is being suppressed, the healthy experiencing self. Again, analogous to IC, when psychological contact between the self and imagined other is critical to the success of the intervention, contact between the two sides of self is critical to the success of two-chair enactments. This promotes clients’ experiential awareness of agency and the role they play in the self-interruptive process. Once the client enacts their interruptive (and anxiety-producing) process, they are directed to switch chairs and attend to their internal experience in response to being shut down and threatened (bottom of Figure 8.1). Specify and Differentiate the Negative Message During the next step, therapists ask clients to elaborate and express their position (top of Figure 8.1) to the suppressed and/or frightened experiencing part of the self (e.g., “Don’t say anything because you will look weak,” “Don’t say anything because you will be taken advantage of”). This is the specific content of the dominant negative message. Clients should also be encouraged to pay attention to their vocal quality, the implied warning, or domination. This increases client awareness of the specific imagined dangers—in this case, of speaking up (bottom of Figure 8.1) and the negative impact this has on self. Intensify the Negative Message Once the specific negative message is identified, intensification interventions (top of Figure 8.1) by the therapist and evocative empathy can be used to exaggerate this message (e.g., “Never, under any circumstances, show your feelings; keep them tightly bottled up inside”). Clients could be encouraged to attend to bodily experience and affect directed toward the experiencing self (gestures of warning, demanding, pressuring) or enact how they stop themselves from

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feeling and expressing “their truth” (e.g., “It is almost like you literally stop yourself from speaking, isn’t it? Can you try doing that on purpose—see how it works? What is it like if you put your hand over your own mouth as you try to speak?”). Such enactments are sometimes contrived, but they bring to awareness the agency a client has in actively holding themselves back. They also are intended to evoke a response in the experiencing self (bottom of Figure 8.1). The therapist then asks the client to switch to the experiencing chair (bottom of Figure 8.1), directs their attention to the negative impact and discomfort of the self-interruptive message, and communicates this to the dominant other (e.g., “Stay with that, tell this other part of yourself how it feels when he shuts you down. Tell him about the effect this has on you”). In one creative example using enactment and embodied experience, a client said she “pushed her feelings to the side.” The therapist encouraged her to enact pushing her feelings (in a backpack) further and further to the side until she was eventually crouching under a table. This elicited client discomfort and an expressed desire to get out—the next step in the resolution process. Such enactments are expressions of tacit and implicit processes of how people may be constricting or prohibiting their feelings. Making that process palpable and deliberate is a key aspect of bringing the unhealthy process into awareness. Notice that cognitive approaches focus on catastrophic expectations, which has some affinity here, but the process of self-interruption and inhibition typically involves a process that is deeper than the words or beliefs. There is frequently also a preverbal and body-based component to staving off one’s feelings. Elicit Healthy Protest and Needs Increased experiential awareness of the negative impact and discomfort of squashing or scaring the self (e.g., tension, difficulty breathing, collapse into powerlessness) elicits mixed feelings in a client. While part of the experience is painful and aversive, it typically also elicits a healthy defensive protest (bottom of Figure 8.1). The therapist’s task at this point in the task is to identify and promote these latter reactions to mobilize healthy strivings for selfexpression, which challenge maladaptive self-interruption This process resembles cognitive interventions intended to increase awareness of irrational beliefs about the dangerousness of internal experience. However, rather than emerging from a top-down rational or logical process (as in a cognitive approach), the challenges in EFTT are generated bottom up, emerging from the client experiencing the impact of squashing oneself in the session. Further, while a cognitive approach typically looks for “evidence against” to clarify the “rational truth” for clients, an emotion-focused approach emphasizes the aversive affective reaction to being squashed, an entirely different way of mobilizing assertion. The client is encouraged to present the perspective of the experiencing self: “Make her see how important it is to express yourself” (bottom of Figure 8.1).

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The therapist supports the client’s emerging felt need and encourages them to express feelings and associated needs to other parts of the self. Access Values and Standards The client then switches chairs and responds to expressed needs from the dominant part of the self (top of Figure 8.1). This step is critical because it involves identifying and articulating the core concerns that have motivated self-interruption. This part of the self may express fear of change or annihilation, and negative messages shift to represent healthy values and standards— for example, efforts to protect the self (e.g., “You need me; I am afraid if you open up, you won’t be able to handle it,” or “I am afraid if you open up, you will get hurt”). This interaction between the two parts of the self is repeated until both parts understand the perspective of the other. Promote Self-Understanding and Negotiate a New Interaction In hearing and appreciating the perspective and needs of the experiencing self, the dominant negative part of the self presents their perspective from a softer, more vulnerable stance (top of Figure 8.1). The experiencing self, in turn, begins to appreciate the core concerns that drive the other part of the self (bottom of Figure  8.1), and they negotiate a new interaction—ways to honor adaptive needs for expression, as well as values and standards (e.g., “I know you are trying to protect me, but it’s not working anymore. It would be better if you let me . . . at least try”). The other side of the self agrees to offer new positive messages and support the client in their desire for more adaptive behavior. In working with clients experiencing complex trauma, however, this is when it frequently becomes clear that the client does not know how to be supportive toward themself and requires instruction. The therapist works with the client to help identify exactly what encouraging and supportive messages would be more helpful coming from the dominant part of the self (e.g., “You will be okay; I think you are strong enough to handle this, or you can ask someone for help”). This involves experiencing the impact of different potential supportive messages to see which one feels best for the individual client. The dominant part of the self agrees to try this new supportive behavior in the future. Reintroduce IC or EE Because interrupted feelings in EFTT frequently concern perpetrators of harm, in this final step, it might be a good time to reintroduce the IC procedure (or EE alternative) and help the client express previously inhibited feelings to this imagined other (or to the therapist, in the case of EE). Once the client can fully express and explore the meaning of these feelings, the task shifts, and the client moves on to resolving issues with perpetrators. This is carried forward in the third phase of EFTT. Case Example of Self-Interruption in the Context of IC An example of working with self-interruptive processes occurred with the client, Lynne, who had difficulty confronting her emotionally abusive mother

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in IC (Paivio, 2016). She disclosed anger at her mother’s abuse, but immediately on introduction, the IC evoked fear and difficulties continuing. This illustrates the power of the IC to activate the core trauma-related emotion scheme. The therapist validated her fear and provided the process observation that “Mother has power to shut you down, even though she is not here.” She then briefly explored Lynne’s fear and provided encouragement and support to push through the block. THERAPIST:

What holds you back?

CLIENT:

I don’t know. It’s just intimidating to say out loud because it makes it more real.

THERAPIST:

Ah, yes, saying it out loud makes it more real. But your experiences ARE real. What you have to say is powerful, important.

CLIENT:

Yes [laughs shyly].

THERAPIST:

I will be here to help; there are no rules. Are you willing to try?

These responses helped Lynne access anger at her mother’s abuse, but again, she quickly shut down, interrupting her experience: “I draw a blank, feel like I am pushing it away.” This indicated that self-interruption could not easily be bypassed and was a marker for intervention to explore and reduce the selfinterruptive process. The therapist identified the struggle between parts of the self (marker)— “Yes, so many deep feelings, but part of you is pushing it away”—and switched to a two-chair dialogue to explore the conflict and help her allow healthy anger and sadness. The following excerpt illustrates the therapist’s process directives to access the negative messages of the dominant part of the self and evocative empathy to exaggerate the negative message and potentially evoke an adaptive reaction. THERAPIST:

What do you say to this part of you that feels? How do you push it away?

CLIENT:

Don’t go there . . . pretend it didn’t happen.

THERAPIST:

Pretend, be a phony [exaggerate, intensify]. Why tell her why she should not go there?

CLIENT:

It’s scary.

THERAPIST:

Scary. Tell her the bad things that will happen if she expresses her feelings [elicits specificity].

CLIENT:

You will feel weak . . . it scares me that she will know what I am saying here.

THERAPIST:

So, do not speak your truth.

CLIENT:

It’s too hard; easier to pretend.

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The following excerpt again illustrates an intervention to intensify the negative messages to evoke a reaction, alternative adaptive feelings and needs in the experiencing self, then helping the client express this new experience and perspective to the interrupting part of the self. THERAPIST:

You don’t want to feel vulnerable. So, don’t let it out. Never open up about your feelings [exaggerate, intensify].

CLIENT:

It sounds awful!

THERAPIST:

So, the other part of you says it sounds awful. Switch chairs. Tell her what’s awful about never speaking your truth.

CLIENT:

It doesn’t make sense to not talk about it, bottling it up.

THERAPIST:

Maybe tell her the benefits of talking about it [seeking specificity about healthy protest].

CLIENT:

You will get it off your chest.

THERAPIST:

How does it feel to bottle up? [integrate embodied affect into healthy protest]

CLIENT:

I don’t like feeling all tense and bottled up. I want to get it off my chest.

THERAPIST:

How would that feel to get it off your chest?

CLIENT:

I would feel lighter.

THERAPIST:

Lighter. Can you feel that now? [hand on chest; enhancing emotional awareness]

CLIENT: [brief silence, attending inward] Yes, it’s a relief. [tears in eyes] THERAPIST:

So, it touches you; better to express. Are you okay to go back to your mother?

The emergence of a desire for authentic expression is a marker for switching back to IC with the mother and encouraging the expression of previously interrupted anger. When Lynne again shuts down and admits she “went numb, zoned out,” the therapist encouraged her to recall a specific event with her mother—an autobiographical memory—to deepen her emotional engagement. Lynne recalled an incident in which the mother cruelly insulted and degraded her younger sister, called her fat, and insisted she eat out of the dog bowl. THERAPIST:

So insulting!

CLIENT:

It is!

THERAPIST:

Tell Mom how you feel remembering that incident.

CLIENT:

You have no right to talk to her that way . . .

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THERAPIST:

So damaging.

CLIENT:

Yes, it’s so damaging . . . you should want the best for your kids . . . plain and simple, you are a bully.

The therapist supported her increased assertiveness and promoted an increased sense of entitlement to unmet needs. In processing the therapy experience at the end of the session, the therapist asked how Lynne wanted to go forward: “What if she bullies you again?” Lynne acknowledged she had a lot more to say and did not want to keep living in the past; she wanted to be herself: “I won’t let her bully me anymore.” This was the beginning of an increased ability to express authentic feelings and needs to construct a stronger sense of self. With clients like Lynne, working through self-interruptive processes and reengagement in IC can typically continue over several sessions. Catastrophic Expectations About External Situations Self-interruption can involve implicit or explicit catastrophic expectations about internal experience. These can be directly challenged by providing information about the nature of emotional experience and worked with in two-chair dialogues. Experiences of trauma frequently result in unrealistic beliefs, not only about internal experience but also about the dangers of situations and consequent avoidance of these situations. In cases of complex PTSD, these perceived dangers and beliefs are frequently interpersonal (e.g., “I will get hurt,” “I will be abandoned,” “I will lose my sense of self”). The model of resolving intrapersonal conflicts described earlier can also be applied to reducing catastrophic expectations and anxiety about external situations whereby therapists ask clients to specify and understand how they make themselves afraid. For example, during Phase 2 of therapy with the client Martha, described earlier, who had been abandoned by her husband, the focus shifted from her past issues to the conflict between wanting companionship and the fear of beginning another intimate relationship. From the dominant, fear-producing part of herself, Martha was asked to specify anticipated dangers that prevented her from entering a new relationship (“You will become too needy and dependent, put up with anything, be devastated by another rejection”). This process activated the core emotion structure in the experiencing part of the self in the other chair—pain and devastation at abandonment and the belief that her neediness caused her abandonment and pain. Therapist interventions validated her need to protect herself and, at the same time, highlighted and exaggerated her anticipated dangers (e.g., “So you can’t trust yourself— you will be so needy you will settle for anything; you will be blind to signs of danger; you will be destroyed, so you better not get involved”). The therapist then encouraged her to attend to her response to these internally generated warnings. It is important to note that these therapist highlights and

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exaggerations are not delivered as confrontations but rather as empathic reflections of implicit meaning. As a result, this elicited sadness at the prospect of remaining alone for the rest of her life made Martha more aware of a desire for companionship and intimacy. Interventions supported the emergence of these healthy resources (“Say more about how important companionship is to you”), which, in turn, accessed challenges to catastrophic expectations (“Why should I be a lonely old woman? I am not the vulnerable young mother I used to be. I’ve learned a lot in 30 years”). The therapist supported this self-affirming stance. Challenges can always emerge for the therapist when using the interventions for fear, anxiety, and avoidance, as described in this chapter (e.g., healthy protest does not spontaneously emerge). These are similar challenges to those that emerge when working with guilt, shame, and self-blame. We discuss difficulties when working with fear and shame at the end of the next chapter.

9 Transforming Guilt, Shame, and Self-Blame

T

his chapter focuses on transforming guilt, shame, and self-blame generated by self-critical processes as a continuation of Phase 2 in therapy. Clients cannot move forward and resolve issues with perpetrators and hold them accountable for harm until they stop blaming themselves; they cannot sustain healthy relationships until they feel more compassionate toward themselves. As discussed in the preceding chapter, maladaptive fear and maladaptive shame are closely related in terms of action tendencies and are considered functionally equivalent; they both lead the client to either withdraw or collapse and are associated with obvious maladaptive thoughts or self-statements (catastrophizing, self-criticism) and a core maladaptive sense of self (see Chapter 3, this volume). Therefore, many of the change processes, intervention principles, and strategies presented in this chapter resemble those presented in the preceding chapter. However, in cases of complex relational trauma, shame is frequently more dominant than fear and more central in the damage to a client’s sense of self. Feelings of shame are extremely painful, frequently avoided, and difficult to access in therapy. This, in turn, makes these feelings notoriously difficult to change. Working with shame, therefore, presents unique challenges for the clinician. This chapter is structured like the preceding ones. We place emotion-focused therapy for trauma (EFTT) in the context of other approaches for reducing shame, describe different types of shame experience as observed in trauma therapy, and then describe the change processes and goals specific to our

https://doi.org/10.1037/0000336-010 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  207

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approach. The last half of the chapter focuses on intervention, and again, many of the strategies parallel those described in the preceding chapter. Material that is uniquely relevant here includes working with adaptive shame about violating one’s personal standards, shame–anxiety underlying social phobia, and guidelines for changing hostile self-criticism using two-chair dialogue. We also present a section on accessing self-soothing resources, which is relevant to working with both fear and shame. As noted in the preceding chapter, if we are to ask clients to get in touch with their most threatening and painful experiences, we must also ensure they have the capacity to comfort themselves. The chapter concludes with a section on addressing difficulties in working with both fear and shame.

PERSPECTIVES ON GUILT AND SHAME: EFTT COMPARED WITH OTHER APPROACHES Guilt, shame, and self-blame are recognized as defining features of both posttraumatic stress disorder (PTSD; American Psychiatric Association, 2013) and complex PTSD (World Health Organization, 2019) stemming from interpersonal trauma. Reasons for this were presented in Chapter 1 on trauma. To briefly review: First, victimization—being rendered powerless and stripped of one’s dignity—is profoundly humiliating. Victims frequently share the belief that people are entirely responsible for their own fates and circumstances, and they, therefore, blame themselves for their victimization. Furthermore, complex trauma can include overt or implicit messages of blame and shame from the actual perpetrators that, over time, erode self-esteem. It also has been suggested that self-blame provides an element of perceived control over otherwise random acts of violence. It may be less threatening for a child to blame themself, for example, than to accept that an attachment figure on whom they are completely dependent is unreliable or dangerous (Winnicott, 1965). Another reason for the centrality of shame in trauma is its prominence in many disorders that are comorbid with complex PTSD. Thus, shame has been called a transdiagnostic emotion. Shame is intrinsic to self-critical depressions, for example, as well as lingering depression at loss (Greenberg & Paivio, 1997; Pascual-Leone & Greenberg, 2007). Accordingly, a history of rejection by attachment figures results in a core sense of self as defective and, therefore, vulnerable to abandonment. Later adult experiences of actual loss or rejection seem to confirm this shame-based sense of self. Similar processes are thought to be involved in specific types of personality pathology. Borderline and narcissistic rage, for example, is considered a defense against core feelings of shame, and avoidance of interpersonal contact, which is characteristic of avoidant personality, protects against morbid fear of rejection (projected shamebased sense of self). Likewise, social and performance anxiety can be rooted in a fear that others will see one’s essential defectiveness. Sexual victimization is particularly stigmatizing. Victims of child sexual abuse not only are disgusted

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by perpetrators but are also disgusted with themselves; they feel contaminated or “dirty.” Behaviors such as substance abuse and self-injury can function to numb feelings of shame, and engaging in these behaviors, in turn, can generate additional shame. In terms of intervention, traditional cognitive and behavioral approaches focus on changing the self-critical thoughts associated with depression and the self-blame associated with trauma (e.g., Beck, 2021; Foa et  al., 2019). However, there is increasing recognition that shame rooted in early attachment experiences can be difficult to treat with standard cognitive behavior therapy (CBT) methods and can interfere with the therapeutic relationship (Ford & Courtois, 2020). Other approaches to reducing shame target these more complex meaning systems. For example, as discussed in the preceding chapter, dialectical behavior therapy (Linehan, 2015) emphasizes the importance of therapist validation to reduce underregulated shame and promote selfacceptance. Other approaches (e.g., compassion-focused therapy; Gilbert, 2014) use a variety of experiential tools to help clients explore and revise the inner dialogues they learned as they grew up and develop self-soothing capacities. Although these approaches share similarities with EFTT, they are, in contrast, essentially skills training models. EFTT may incorporate skills training strategies, but it relies primarily on experience-based intervention within a session to activate maladaptive emotion and then access alternate healthy emotional experiences to modify the emotion scheme. EFTT does this using interventions such as empathy, deepening experiencing, and imagery techniques. Many psychodynamic relational models also understand shame as originating from a core sense of self that develops through negative attachment experiences (e.g., Benjamin, 1996; Fairbairn, 1952; Kohut, 1984). More recent accelerated experiential dynamic psychotherapy (AEDP; Fosha, 2021) draws on Winnicott’s (1965) views concerning the “true self” that embodies authentic feelings and needs and the “false self” that squashes authentic experience to secure approval. AEDP emphasizes the provision of a secure attachment bond that helps clients relinquish their defenses and access suppressed feelings and needs. These concepts are useful metaphors used in EFTT and have obvious similarities to Rogers’s (1980) views concerning the necessary and sufficient conditions of change—the therapeutic relationship qualities that undo “conditions of worth” and help clients access authentic experience. Such views are particularly compatible with EFTT.

PROCESS DIAGNOSIS: DISTINGUISHING DIFFERENT TYPES OF SHAME EXPERIENCE As with fear and anxiety, presented in the preceding chapter, EFTT distinguishes among different types of shame experience, and these distinctions inform appropriate intervention. These types are described in the following subsections, beginning with adaptive shame.

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Adaptive Shame Shame is characterized by feeling exposed and condemned as lacking in dignity or worth, feeling looked down on or inferior in the eyes of others (Greenberg & Paivio, 1997). Seminal emotion theory and research (e.g., Izard, 1977) indicate that the capacity for shame develops with the capacity for self-consciousness around 2  years of age. Shame-related experiences include self-consciousness, embarrassment, humiliation, and a sense of worthlessness or inferiority. The action tendency associated with shame is to withdraw or hide so that personal flaws are not exposed. Shame reduces facial communication and involves lowering the eyes, shrinking the upper body, pounding of the heart, and blushing. The hiding response associated with shame is captured in expressions such as wanting to “disappear” or “crawl into a hole.” In the context of individual psychotherapy, the shame being explored is more often maladaptive, although the basic shame response has been evolutionarily adaptive. The adaptive function of shame is to protect social standing and connectedness and promote belonging and conformity to social standards among one’s group. The public shunning practiced by certain cultural groups as a punishment for violating social standards exemplifies this social function. Adaptive shame appears in couples therapy, for example, when an individual feels ashamed for having transgressed or violated the shared values of a relationship, such as fidelity (e.g., Meneses & Greenberg, 2011). In other cases, victims of developmental trauma may experience adaptive shame at having perpetuated abuse toward others. Maladaptive Shame The following subsections describe two types of maladaptive shame that, along with fear or anxiety, define core affective features related to complex relational trauma. Primary Maladaptive Shame Primary maladaptive shame was the focus of our earlier chapter on trauma reexperiencing and memory work. Abused and neglected children grow up with a sense of themselves as fundamentally flawed and bad and maintain this sense, sometimes despite explicit beliefs to the contrary. For example, a client reported, “I know it’s ridiculous to be so concerned about making small mistakes, but I feel like it’s terrible, like I’m some kind of criminal.” These individuals can also feel that they were somehow responsible for their own maltreatment, even though, intellectually, they know that children cannot be held responsible for such acts. As in the case of primary maladaptive fear, this sense of self is a holistic, implicit, and embodied emotion scheme or meaning system composed of thoughts, feelings, and somatic-sensory experience. When activated, this emotion scheme generates feelings of shame and may generate explicit critical self-statements.

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Secondary Maladaptive Shame Secondary shame is typically more circumscribed and less entrenched than primary maladaptive shame. Secondary shame is related to some other (more primary) emotional experience. Embarrassment about disclosing what happened, shame about one’s deeper emotion (e.g., vulnerability or fear, jealously, anger), or shame about one’s trauma or depressive symptoms (being unable to recover) are examples of secondary shame. We return to the distinctions between primary and secondary maladaptive shame later in the intervention section of the chapter. Other Emotions Related to Shame Shame also is related to and frequently coexists with other emotions. The following subsections describe these distinct emotions and their relationship to shame. Guilt While shame is about being unacceptable in the eyes of others, guilt is about wrong-doing, but in practice, the two emotions can be closely connected depending on a client’s concern. As such, guilt can provide adaptive information when it concerns actual transgressions (e.g., perpetrating abuse or neglect), in which case the action tendency is to make amends or change the behavior. For example, in complex trauma, adaptive guilt may be about betraying one’s values or making unfortunate choices in what are often complex and harrowing situations (e.g., “I wish I had done what I thought was right, but I didn’t. I left him to the wolves . . . and so what happened to that kid was really my fault; it’s on my hands”). Maladaptive guilt associated with trauma, however, involves victims erroneously feeling responsible for their own or others’ victimization (e.g., “Even though I hated it, my body was responding sexually . . . somehow it feels like it was my fault that the sexual abuse went on so long”). In-session markers of guilt include implicit or explicit “should” or critical self-statements that resemble markers of shame. Another example of maladaptive guilt occurs when witnesses of maltreatment suffer survivor guilt (e.g., “It should have been me rather than my twin sister who was getting beaten. I don’t know why they picked her as the scapegoat for every little mistake I made”). Shame–Anxiety Social anxiety can be secondary to core feelings of inferiority (shame) so that people fear being exposed as such (e.g., “I’m anxious they will see through me and realize what a fool I really am”). Although anxiety is salient, it is a secondary emotion. Meanwhile, the underlying issue of primary shame frequently stems from a history of being berated or humiliated for failures or shortcomings, and the individual subsequently fears any possible reliving of that. (For an elaboration of this issue in relation to social anxiety disorder,

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see Elliott & Shahar, 2019.) Shame–anxiety involves overcontrol and overmonitoring the self and an inability to be spontaneous for fear of exposing defective aspects of the self. Individuals plagued with shame–anxiety are vigilant for signs of disapproval, have difficulty asserting themselves or saying “no” for fear of rejection, and may engage in extraordinary efforts to please others. Shame–anxiety is also observed in the therapeutic relationship when clients fear disclosure and judgment from their therapist and can interfere with a client’s participation in key interventions. This was discussed in Chapter 4 on the alliance. Anger, Contempt, and Disgust Directed at the Self Clients can feel disgust at thoughts, values, people, or anything else they view as offensive. Contempt can be thought of as a blend of cool anger and disgust; it is rejection that is haughty and superior. Disgust and contempt, when directed at another person, serve the same distancing function as anger. These feelings can be adaptive when directed externally and in response to violations of one’s physical integrity or rights and standards, but there are several ways they can be problematic. For example, when they become chronic ways of responding to others, it can indicate character pathology and is sometimes related to unresolved complex trauma (Pascual-Leone et al., 2013). Anger, contempt, and disgust are also typically problematic when directed at the self. These are the affective qualities that drive self-critical cognitions and statements. Together, these cognitive–affective processes are activated along with a core shame-based sense of self and can contribute to or perpetuate maladaptive shame.

CHANGE PROCESSES AND GOALS Change in emotion-focused therapy is contingent on clients’ awareness of emotion, ability to regulate and reflect on emotional experience, and ability to activate healthy self-protective experiences that can modify maladaptive emotion schemes. The process of engaging and transforming maladaptive emotions, including maladaptive shame, is presented in the general model of emotional processing (see Figure 3.1 in Chapter 3, this volume; Pascual-Leone & Greenberg, 2007). This is the essence of emotional transformation, regardless of the procedure. Thus, once shame is identified as the source of client distress, interventions access specific negative self-evaluations (“I’m no good,” “I’m defective,” “I’m unlovable”) and unmet needs (i.e., for self-respect, compassion toward self) that are part of the emotion structure. The exploration process then shifts to the client activating healthy internal capacities in the form of more positive self-evaluations and a sense of entitlement to unmet needs (e.g., “I deserved encouragement and support, not that constant criticism”). This, in turn, activates assertive anger at maltreatment or sadness about losses, both of which are associated with adaptive action tendencies.

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These adaptive emotions help to counteract shame, which is a classic example of transformative emotional processing. A goal of EFTT in working with shame (as with fear) is to help clients allow previously avoided painful experiences of shame to integrate the associated information into the self. Change necessarily involves gradual exposure to potentially overwhelming shameful memories, as described in the earlier chapter on memory work. Interventions also help clients explore and construct new meaning concerning shameful traumatic experiences and promote client agency and self-control. This occurs through a gradual awareness of how internalized self-critical processes contribute to undermining the client’s self-esteem.

INTERVENTION PRINCIPLES RELEVANT TO SHAME The following emotion-focused therapy intervention principles are particularly relevant to working with shame-related processes. Affirming Client Vulnerability We have presented numerous examples of affirming vulnerability throughout the text, but this is perhaps the most important principle related to therapeutic work with shame. Clients feel highly vulnerable disclosing embarrassing or humiliating experiences. Simple statements by the therapist (e.g., “Yes, I know it’s hard to talk about this”), communicated with gentleness and compassion, are invaluable in reducing anxiety so that clients are willing to disclose hidden aspects of the self. Of course, affirmation of vulnerability should precede attempts to explore shame-related experience. Markers that indicate a client’s vulnerability and require therapists to respond to it explicitly include overt expressions of shame or embarrassment, reluctance to disclose, and a vocal quality of “confession” or revealing deeply held secrets. After affirming client vulnerability, therapists also can prompt for further disclosure through the provision of support (e.g., “These secrets are toxic; it’s important to get them out in the open—here, where it’s safe”). Refocusing Client Attention on Internal Experience Refocusing client attention is frequently necessary in shame work because deflections away from experiences of shame are intrinsic to this emotion. Clients can frequently talk about or around shame-inducing experiences but will avoid full engagement to curtail their discomfort. Interventions such as “Let’s go back . . .” can refocus attention on core shame experience. Therapist interventions can also validate reactive anger as an automatic coping strategy and follow this by directing the client’s attention to an underlying core experience of shame (e.g., “Can you also get in touch with that feeling of being used? That’s the damaging part”).

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Being Present Centered Being “present” involves the therapist directing clients’ attention to what they are experiencing in the moment (e.g., “What are you feeling right now as we talk about this?”). The difficulty with shining a spotlight on shame experience is that it risks increasing a client’s self-consciousness and may thereby promote further withdrawal from their emotional experiences (i.e., avoidance) and perhaps from the therapist. However, one area in which this is essential is increasing clients’ awareness of their own agency in contributing to shame through self-criticism. In two-chair work, clients are encouraged to direct self-critical statements at themselves and then attend to the experiential impact of that criticism in the moment. Articulating the Meaning of Nonverbal Expression Articulating the meaning of nonverbal expression involves directing clients’ attention to the vocal quality of contempt and disgust associated with their verbal content. The content of self-critical statements is typically not as hurtful as how they are delivered. For example, when a client expresses self-criticism with a tone of harsh self-contempt, the therapist helps them articulate the implicit meaning of the vocal quality. Elaborating the meaning implied within a nonverbal or paraverbal expression can also help identify the origins of negative self-statements (e.g., the therapist might ask, “Whose voice is that? Is that you or is that your father talking?”). Client gestures, sighs, and vocal qualities can indicate feeling hurt, defensive, or bad about the self in response to criticism. Directing attention to these nonverbal expressions increases experiential awareness of the negative impact of self-criticism. This helps mobilize protective parts of the self that do not accept such harsh treatment and assert healthy existential needs. Promoting Agency Ownership of experience or acknowledging agency occurs in two ways. First, clients are encouraged to enact how they “make themselves” feel ashamed to specify their beliefs about what is so deeply wrong with them. Therapists will need to begin by validating that there are interpersonal origins for these messages, but eventually, clients must understand that they are contributing to their bad feelings (e.g., “Your mother is no longer here putting you down. It’s like you have come to believe these things. This is now a battle between you and you”). Client ownership of experience can serve as an insight into how their depression or anxiety is being increased or maintained. This metaawareness increases their sense of control over the problematic processes, which opens the way to conscious choice and change. This ushers in the second way that EFTT therapists promote agency, which is to promote new adaptive experiences such as fighting back, assertion, and aspiring for change. Promoting agency in this way comes through fostering the bottom-up emergence of experience rather than conceptual homework or

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aspirational efforts. For example, therapists can look to identify and then bolster moments of assertion that may otherwise be a fleeting part of experience (e.g., “I hear the firmness in your voice when you say that. Can you try saying that to him [the imagined other]: ‘I did NOT deserve that!’”). This is followed by directing the client’s attention to their experience of this new adaptive response. Increasing Emotional Intensity During two-chair work, intensifying client emotional experience lends impact to self-critical statements and reveals the implicit self-loathing, disgust, or contempt to activate the shame-based emotion structure. This, then, is available for exploration and change. Deeply experiencing the pain of self-criticism helps to activate alternative self-protective resources to counteract the harm. When clients are resistant to focusing on shame experience (because it is so painful), it can be helpful for the therapist to intensify the damaging effects of hiding and constant vigilance to keep shame experience at a distance (e.g., “I know every fiber of your being wants to push it away, but that’s such a strain—to be on guard all the time”). Offering Process Observations Offering observations to clients as feedback about their process in the moment is important because clients are often unaware of (through avoidance) or reluctant to acknowledge shame experience. Process observations help clients reflect on their core emotional state and contribute to developing a collaborative understanding of the generating conditions for disturbance. For example, a therapist might observe that a given client frequently has a belittling tone of voice when she talks about herself (e.g., “Yes, and when you criticize yourself, I hear your tone of voice. It’s like a looking-down-my-nose-at-you sort of voice. What is the message being sent by that tone of voice?”). Evoking Memories Strategies are used to access autobiographical episodic memories of experiences in which the client’s sense of self as worthless or defective was formed or present situations in which this sense of self was activated. This was the focus of Chapter 7. Once activated, these memory structures yield new information about the self and situations that is then available for exploration, emotional processing, and change.

INTERVENTIONS FOR REDUCING SECONDARY SHAME As noted earlier, shame stemming from attachment relationships is particularly difficult to access and explore in therapy. Therefore, when broaching these client experiences in therapy, it is particularly important for therapists

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to distinguish different clinical presentations related to shame. The following subsections clarify these points. Secondary Shame About Internal Experiences Clients can feel ashamed of any internal experience that is deemed unacceptable. This secondary shame prevents the full engagement of deeper issues, including issues related to primary maladaptive shame. This secondary shame process can be closely related to the avoidance of internal experience discussed in the preceding chapter. Obvious markers are explicit self-consciousness, embarrassment, or efforts to hide or avoid specific topics and experiences. A common example is clients’ shame about their trauma symptoms. Intervention with disavowed experience typically involves exploring beliefs about emotion or the risks of being vulnerable and using empathic affirmations to help the person face the disavowed state. In the example of shame about trauma symptoms, interventions also can include education about the nature of trauma and the difficulty of recovery. This is especially useful in the context of a client’s limited social support and any societal attitudes the client has internalized, such as having little tolerance for prolonged grieving over the loss of loved ones. Validation and interpersonal warmth play key roles in moving clients past these secondary experiences. Addressing Shame Underlying Social Anxiety Initially, in therapy, socially anxious clients might only be aware of their anxiety and less aware of underlying core feelings of worthlessness or inadequacy. It can also be difficult for clients to admit that shame is the core issue—what amounts to their anxiety and embarrassment about feeling and being unworthy (i.e., secondary anxiety about primary shame). The first step in intervention, therefore, is to arrive at a collaborative case formulation and understanding that social anxiety is driven by primary maladaptive feelings of shame. In some cases, it is sufficient for intervention to focus on obvious negative self-statements. In other cases, it is necessary to access the core self-organization by activating formative emotion memories. For example, one anxious and avoidant client had chronic feelings of inferiority and worthlessness that were internalized from the abuse of a critical stepfather. He found it impossible to engage in two-chair work for fear of losing control and looking stupid, and he was extremely emotionally blocked. Therapy attempted to explore how he made himself feel anxious, but again, anxiety interfered with the exploration process. Successful treatment first needed to reduce his anxiety in the session by providing structure, for example. Another socially anxious client with a history of severe emotional abuse discussed receiving a promotion at work, then automatically feeling afraid that she would not be able to live up to the expectations, and then feeling anxious

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that her boss and coworkers would see her nervousness and evaluate her negatively. This reveals a sense of primary shame about her (felt) inadequacy and secondary anxiety about being “found out.” EFTT intervention involved validating the secondary anxiety (as a real experience) and redirecting her attention to and exploring the deeper primary feelings of incompetence. This required arriving at a mutual understanding that this sense of self is what needed to change. For example, the therapist said, I know you don’t like feeling so anxious in these situations, but my sense is that what’s really going on is a deep sense of yourself as incompetent or inferior. Your anxiety is the fear that others might see this “defective you” that comes from all those experiences of being humiliated as a girl. If we can change those deeper feelings of defectiveness or inferiority, I think your anxiety will disappear. Does this make sense?

The client immediately recognized this as true. The focus of therapy then shifted to strengthening her sense of self through memory work rather than challenging the anxiety-producing cognitions.

INTERVENTION FOR PRIMARY ADAPTIVE SHAME ABOUT VIOLATING PERSONAL STANDARDS This section addresses another area of possible confusion for clinicians: the notion of adaptive shame. It is not uncommon for clients with histories of complex PTSD to engage in self-destructive behaviors as strategies for coping with emotional pain, including the pain of shame. Ironically, people also frequently feel ashamed of themselves for engaging in these behaviors, and self-condemnation can be accompanied by a fear of being found out, stigmatized, and rejected. Many trauma survivors also feel responsible for causing harm or failing to protect others who were even more vulnerable. Other clients feel ashamed about having participated in morally unacceptable behavior during their own sexual abuse, for example. Before deciding how to intervene in these cases, a distinction must be made between behaviors over which clients had or did not have control. When clients feel ashamed about behavior over which they have control (e.g., substance abuse, neglecting one’s children), the goal is to shift their overgeneralized shame and self-condemnation (e.g., “I am a despicable, bad person”) to guilt and regrets about the specific behavior or mistake and then mobilize a desire to make amends or change. In short, the aim of this intervention is to make use of the primary adaptive shame that clients have about violating their personal standards. The first step is to acknowledge and empathically affirm the difficulty of facing painful and shameful memories and acknowledge the client’s courage in disclosure. Therapists communicate unconditional positive regard for the client, compassion for their suffering, and a matter-of-fact attitude toward the content. Intervention then involves

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exploring the client’s values and increasing awareness of the function of the shameful behavior, including the core needs and desires it fulfills (e.g., the need to escape, to be free). Interventions also support the appropriate acceptance of responsibility for the behavior and, at the same time, promote compassion toward the self for imperfection and mistakes and acknowledge the coexistence of different aspects of self. In short, the goal is to change the formulation more clearly from “bad person” to “bad deed.” One example is a client who had been physically and sexually molested by multiple perpetrators, including her parents, and who was also riddled with shame for hitting and sexually experimenting with her younger brother. She felt like cringing when she recalled hurting him the way she had been hurt. She believed that she “should have known better” and was initially reluctant to disclose details of her abusive behavior. Therapist responses that highlighted her desire to be a loving sister and her deep regret helped reduce anxiety (i.e., secondary emotion) about working on this. In addition, the therapist’s reflection that “this is eating away at you” elicited weeping and further disclosures of what she had done. Later, memory work (see Chapter 7) was used to access this client’s motivations, thoughts, and feelings as a child and promote experiencing to construct new meaning. She recalled her fear, anger, and confusion at the chaos in her life during that time and her struggle to handle those situations on her own. This accessed deep sadness and empathy for herself as a child. The therapist also asked how she would feel if her parents expressed regret for treating her the way they did. She acknowledged that she certainly would forgive them. This helped to mobilize self-forgiveness. Finally, she also was able to express regret in an imaginal confrontation (IC) with her brother. Another example of working with adaptive shame was a highly religious and emotionally constricted client who secretly visited massage parlors. On the one hand, he enjoyed the “rebellion” against his church’s moral proscriptions and the excitement of physical contact. On the other, he felt ashamed of “cheating” on his wife and exploiting young women (“They are all somebody’s daughter”). Notice that this is different from self-critical processes because the shame is, in fact, adaptive—it tells him that he is violating important personal values and standards. Successful intervention, in this case, involved validating and helping the client acknowledge and explore his need for freedom and sexual intimacy while also bearing in mind his values and then searching for more personally acceptable ways to get his needs met.

INTERVENTION FOR TRANSFORMING PRIMARY MALADAPTIVE SHAME In the following subsections, we describe the markers and intervention for working with primary maladaptive shame. We follow with steps for working through harsh self-criticism and illustrate with a clinical example.

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Markers of Primary Maladaptive Shame As discussed in Chapter 3, while primary adaptive emotion is biologically driven, maladaptive emotion is the product of learning. In the case of childhood abuse and neglect, primary maladaptive shame is deeply seated in developmental experiences. One of the defining features of complex trauma in attachment relationships is a core shame-based sense of self as irredeemably damaged or worthless. This sense of self is a holistic, implicit, and embodied emotion scheme or meaning system that is automatically activated in current situations, particularly those that resemble the trauma. This core sense of self is frequently at the root of other disorders that are comorbid with complex trauma and covered by other emotions. In cases of social anxiety and avoidant personality, for example, markers for primary maladaptive shame are intense fear of negative evaluation and frequent self-consciousness and embarrassment across situations. Other examples include the sense of worthlessness underlying depression; anger at perceived slights, as in narcissistic rage; and rage at the threat of abandonment as in borderline personality. Obvious markers of maladaptive shame and guilt in therapy are explicit client negative self-evaluations (e.g., “I feel like a defective package with no return policy—it follows me everywhere”) and self-critical statements (e.g., “I should have known better; how could I be so stupid?”). These can be implicit or explicit internalized messages from perpetrators or society. What is so painful and damaging about these negative self-evaluations is the accompanying hostility, contempt, and disgust directed at the self. Thus, markers for primary maladaptive shame are negative self-evaluation and selfcriticism accompanied by a vocal quality and/or facial expressions indicating hostility (i.e., sneer, curled lip, haughty arrogance). Reducing Shame Associated With Self-Critical Processes The intervention strategy for changing primary maladaptive shame is similar to that for primary maladaptive fear. It involves accessing the core sense of self and restructuring it by simultaneously accessing alternate healthy resources (e.g., anger at perpetrators or sadness and compassion for self). This can be accomplished by activating and exploring episodic memories, as described in Chapter 7 on memory work. Alternately, this can be accomplished through two-chair dialogue, described in the preceding chapter (Figure 8.1), that highlights maladaptive self-statements. When there are obvious self-critical statements perpetuating guilt and shame, these are markers for two-chair intervention. Examples are when clients fail at life goals they believe they should be competent at, such as relationships and careers. Other examples are when clients believe they should have been able to stop or control some terrible event, such as a rape, abuse, or an accident. Failure in these instances implies to the client some personal shortcoming or defect. Self-critical processes can also emerge as projections, whereby clients believe that others are criticizing them. For example, the client Claire who had been

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sexually abused by her brother was angry at her parents for minimizing the abuse (“They think I’m exaggerating, making a big fuss over nothing!”). Although it is important to validate a client’s sense of invalidation by significant others, the core issue was her own (internalized) minimization and consequent desperate need for parental affirmation. In such cases, it may or may not be useful for the therapist to tentatively point out the projection (“It seems that your parents’ invalidation brings up your own insecurity, a part of you that fears that maybe you are exaggerating”). The client may or may not accept such an interpretation in the moment but, over time, will come to experientially understand that it is her own internalized shame that makes her vulnerable to the real or imagined negative evaluations of others. Regardless, the goal in the moment is for the therapist to help their client clearly articulate the imagined criticisms (“What do you imagine they are saying or thinking about you?”), direct these at the self with associated hostile affect, and elicit the client’s reactions to these condemnations. Because criticism hurts, a need for comfort and support emerges in reaction to the experienced condemnation. Exploring the authentic feelings and needs in response to harsh criticism helps activate internally generated challenges to this self-denigration. As in memory work, described in Chapter 7, activating healthy internal capacities is easier if the person has had prior life experiences of compassion, nurturing, and pride. When clients are unable to feel the experiential impact of their own criticism or alternate healthy experiences do not spontaneously emerge, interventions need to facilitate the process. The therapist can ask, for example, how a child or a friend might feel hearing such criticism and what they would need to hear instead or how the client would feel if they heard support from a friend. This type of self-soothing is described in detail in a later section. Again, the process is one of accessing new information through imagined experiencing. Steps in the two-chair intervention for resolving self-criticism parallel those for resolving self-interruption, as outlined in the general model (Figure  8.1) presented in the preceding chapter. These are reviewed next, along with distinguishing features of the process, specifically self-criticism and self-blame. The goal is to strengthen the client’s demoralized part of the self by standing up to harsh criticism and defend their self-worth. Structure the Dialogue After confirming a marker for self-critical processes, it is important to provide a brief rationale for working on self-criticism using the enactment of internal dialogues. This is especially important in working with shame and guilt because clients can be hesitant to disclose and do not understand the point of continuing to insult, criticize, or put themselves down. Therapists clarify that the intervention is aimed at understanding their internal process better, then strengthening the weaker, demoralized part of the self so they can learn to stand up to their own criticism. Next, intervention promotes contact or dialogue between the two parts of the self (in the two chairs) and asks the client to start by enacting their internalized critic.

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Specify and Differentiate Self-Critical Statements Interventions encourage clients to tell themselves what is required to be more acceptable (“should” statements). In the case of self-criticism, it is essential to highlight the affect associated with self-critical statements—the contempt or disgust (i.e., in vocal quality) that clients feel toward themselves. Research on self-criticism has demonstrated that it is the affective tone rather than its content, per se, that is most related to psychopathology (Whelton & Greenberg, 2005). Thus, clients can be reminded that it is not what you say but how you say it that counts. It requires considerable trust for clients to reveal what they believe to be their deepest flaws, and therapists need to provide guidance and support in this process. This includes the therapist giving examples, suggesting possibilities so clients may recognize themselves (e.g., “What are you saying . . . that you deserved the punishment?”). Clients who blame themselves for their trauma, for example, need to specify what they feel it says about them as a person that they did not or could not stop it (e.g., the therapist might ask, “So what are you saying? ‘I was so weak, stupid, I must have asked for it’—is that it?”). Clients then are encouraged to switch chairs, experience the negative impact of these self-critical statements, and communicate this impact of the self-criticism in the other chair. Intensify or Exaggerate the Negative Message The point of intensifying the negative message is to increase experiential awareness of how harmful and damaging the message is to activate an adaptive self-protective response. This can be done by the therapist exaggerating the content and/or the vocal quality associated with specific criticisms (e.g., “So you tell this part of yourself that she’s not desirable? My guess is you are pretty mean to her. What do you say? Earlier you called yourself a ‘fat slob.’ So, is it like, ‘Who could love such a fat slob?’”). Once a response is evoked (e.g., the client’s eyes well up with tears at being hurt or anger at unfairness), the therapist asks the client to switch chairs and can help them elaborate the other side of this “self–self” conflict, which is expressing the effect of receiving the criticism (“Tell the critical part of yourself how bad you feel. What it’s like to be put down like that? Tell her what happens inside”). A word of caution: Intensifying the negative message of an internalized abusive other can be tricky in self-critical work and is contraindicated when the message is so harsh it can be retraumatizing or malevolent with no potential for softening. In these situations, memory work presented in Chapter 7 is preferable. Elicit Healthy Protests and Needs Once the negative effects of self-criticism are fully experienced, resolving self-criticism can take one of two paths (see Figure  3.1 in Chapter  3, this volume; Pascual-Leone & Greenberg, 2007). On one path, resolution occurs through a full experience of the self as defective, which activates hurt or sadness and the associated needs for compassion, support, and soothing. On the

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other path, the client argues against the criticism, feels angry at its unfairness, and activates associated needs for dignity and respect. In either case, therapist interventions highlight these needs (e.g., “Yes, it would feel so good, make such a difference, to get that kind of comfort and support. Can you get in touch with that? Say what it would mean to you?”) and help the client feel entitled to having these needs met. Positive self-evaluations are activated along with the sense of entitlement, and interventions support their emergence (e.g., “Tell her [the critical part of self] about your good qualities, what she should appreciate. Make her understand”). Promote Self-Understanding and Negotiate a New Interaction As both sides of the self express their perspectives and needs, a new understanding between parts of the self ideally leads to a softening of the critical side. The judgmental part of the self begins to understand the position of the other and takes a more benevolent stance toward the vulnerable part of the self. Interventions support this process (e.g., “Can you hear his position, how hard it is for him, how much he needs your support and encouragement? What might help him?”). The “negotiation” between the two aspects of the self is now possible, which, in turn, leads to the dialectical construction of something new from disparate or opposite aspects of the self. As in the selfinterruptive process described in the preceding chapter, negotiation can involve exploring the intended function of a criticism—for example, to motivate or protect the self from failure or disappointment or ensure that values and standards are adhered to (see Values and Standards at the top of Figure 8.1). The critical part of the self might also be hesitant to soften for fear of annihilation or abandonment because this part has served to protect the client through trauma and crises. Negotiation with oneself and resolution in these instances involve respecting the intention of and reassuring the critical part of the self. Resolving internalized self-criticism is not the same as resolving the unfinished business of trauma, but there is a continuity between them, one with developmental roots. So, although there are no hard and fast rules, the softening of the critic is more challenging when the internalized critic is the voice of a malevolent abusive other who did not, indeed, wish the client well. In these instances, memory work is the preferable intervention. Switch to IC, Evocative Exploration, or Self-Soothing The two-chair dialogue can switch to an interpersonal process—a dialogue with a critical other. The client might recognize the origin of the critical message, or the therapist could ask, “Whose voice is that?” This is a marker for switching to the confrontation of shaming others. Alternately, the process can shift to the client providing soothing and comfort to themselves. This process is presented in detail in a later section of this chapter. Case Example of a Two-Chair Intervention for Self-Criticism An example of a two-chair intervention for harsh self-criticism was observed with the client Kristen, a victim of emotional and sexual abuse at the hands of her father (Angus & Paivio, 2015). She felt guilty about not protecting her

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younger sibling. The following excerpt begins with the provision of a rationale and structuring of a two-chair dialogue. THERAPIST:

One of the most common and tragic outcomes is victims feel responsible for the abuse and guilty about not protecting loved ones. It might be useful for us to work on that and help you come to terms with those feelings [Client: Yes.] I am going to suggest you carry on a dialogue between two parts of yourself, the part that makes you feel guilty, says certain things like “you should have protected them,” and the other part that feels bad, guilty. We’ll start over here [directs the client to switch chairs]. Here’s Kristen who was not able to protect . . . [points to experiencing chair], and from here [critic chair], what do you say to make yourself feel guilty? You should have . . .?

Here, the client directed her response to the therapist, who then directed her to connect with the other part of the self to promote awareness of agency: “Do it to her so you experience how it works inside you. You should. . . .” The following sequence illustrates the therapist’s empathic responding and process directives to help increase Kristen’s awareness of maladaptive beliefs generating guilt. CLIENT:

You should have told someone. You should have done something.

THERAPIST: So, you should have told someone or something. Say more

about what you should have done [promote specificity]. CLIENT:

[sighs] You should have fought back, stopped him.

THERAPIST:

How do you feel toward her, this part of yourself, that she didn’t fight back? [heighten awareness of maladaptive affect directed at herself]

CLIENT:

I’m angry. You should have protected your family [chastising tone of voice].

THERAPIST:

Notice your tone of voice is kind of lecturing? [gestures, finger pointing and wagging at experiencing chair]

CLIENT:

Yes [laughs, acknowledging that she understands].

In the following sequence, therapist process directives helped elicit the painful reaction of Kristen’s experiencing self and promoted client agency by helping her feel the impact of maladaptive self-criticism. THERAPIST: So, come over here [points to experiencing chair]. How do you

feel hearing that you should have done something? CLIENT:

It’s just like my dad saying that. I feel like I’m not worthwhile [eyes tear up], just weak, like a “nobody,” like I’m just not worth it. I feel bad; I agree with you.

THERAPIST:

Okay, I feel like it’s true: I am a weak nobody.

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In the following sequence, the therapist intensifies the maladaptive message directed toward herself to activate an alternative healthy response. THERAPIST: Okay, come over here again [points to critic chair]. Do it some

more. Make her feel guilty. You’re weak . . . CLIENT:

You’re not worth anything, you’re stupid, you’re . . . [long pause]

THERAPIST:

What’s happening? [hand on heart]

CLIENT:

[weeps] I hear all the things he used to say to me.

THERAPIST:

You hear these messages from your father, and this really hurts, makes you cry? [client nods] So, you have learned to say these things to yourself [Client: Mm-hmm]. It’s like your “father in your head,” beating you up, putting you down [Client: Mm hmm].

The following sequence illustrates directing attention to and promoting the client’s full experience of the healthy reactions and communicating this experience to the other part of the self. The therapist then deliberately coaches the client in a healthy protest to shift the self-narrative. THERAPIST:

Come over here [points to experiencing chair]. What do you want to say to those put-downs, the father in your head?

CLIENT:

Well, it’s not true.

THERAPIST:

Stay with that. Tell this part of yourself what IS true.

CLIENT:

I am strong.

THERAPIST:

Tell all the ways in which you are strong; make her understand.

Here, the therapist is promoting specificity to increase emotional engagement. The client recounts several examples of her strength, and the therapist directs her attention to her internal experience recalling these situations: “Can you really feel how that feels right?” In terms of promoting change, it is critically important that clients fully experience these internally generated challenges because those new and adaptive emotional experiences become synthesized with the maladaptive emotion scheme in the construction of a new sense of self. Just as in the initial IC or evocative exploration procedure, clients typically do not complete all the steps (outlined earlier) of the two-chair dialogue process in a single attempt. Rather, clients repeatedly cycle through the steps in subsequent sessions, moving closer toward a resolution of the conflict and full integration of healthy resources. Nonetheless, it is important to bring a satisfactory closure to the process at the end of each session. This involves processing the client’s experience of the procedure and bridging to the future. For many clients, the first two-chair intervention will simply heighten awareness of their painful self-criticism. Effective intervention then involves reassuring them that this is an important beginning that will contribute to reducing self-criticism in subsequent sessions. Client “homework” can involve observing their internal experience when that critical voice emerges between sessions. The session is

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closed with appropriate attention to a client’s capacity for emotion regulation as needed between sessions. Importantly, as noted earlier, procedures that heighten self-critical processes are not appropriate for clients who have no access to adaptive resources or are suicidal. At the end of the session, Kristen said she did not realize how much her father’s voice was still “in her head”—this was her new learning. When asked how she was going to handle situations during the week when she heard that critical voice, Kristen said she would recall all the things she said in session about being strong. The therapist supported her strategy and encouraged her to recall not only the words and knowing it in her head but also feeling it in her heart: “This is where it will take root.” This is a distinguishing feature of emotion-focused therapy compared with the CBT approach to self-criticism noted in the preceding chapter. The impact of emotion-focused therapy interventions is from the bottom-up experience of adaptive emotional reaction to hostile self-criticism (e.g., “This is what it feels like to stand up for myself. I know what I need, and it feels good!”) rather than top-down rational challenges. In an extended course of EFTT, the dialogue and process with clients like Kristen would need to be repeated for them to fully integrate at a deeply experiential level the new feelings and beliefs. Because her self-criticism is so explicitly an internalized message, therapy with Kristen would likely move into an IC with her father. The following section focuses on interventions for enhancing client compassion toward the self that are used as additions or alternatives to IC to reduce self-critical processes.

COMPASSIONATE SELF-SOOTHING Self-soothing, in its most basic form, is an emotion regulation capacity. The degree to which people compassionately apply soothing to themselves, particularly when they are distressed, is learned in the context of secure attachment. Good-enough parenting involves comforting and calming a child in times of distress. Over time, the child internalizes the attitudes and responses of the parent and can comfort and calm themselves and feel safe and worthwhile in the face of life’s challenges. Children who grow up in abusive or neglectful environments do not receive adequate parental attention and care and thus have limited capacity to comfort and calm themselves. These clients can develop these capacities through the relationship with a therapist, who serves both as a secure attachment figure and a coach in the client’s self-care. In practice, at a deeper level, compassionate self-soothing involves the experience of sorrow and compassion for one’s suffering and pain. This is powerfully transformative for clients who previously have felt only loathing, contempt, and disgust toward themselves. Importantly, EFTT self-soothing procedures (like other standard EFTT interventions) are typically experience based (“hot” processes) rather than skills based. They involve a bottom-up affective response to the experience of one’s emotional pain and distress in the moment. Techniques such as imagining oneself

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as a hurting child can be powerfully evocative and deliberately used to activate core pain. In all instances, the client is helped to deeply experience both the pain and the positive effects of the compassionate self-soothing response. However, EFTT can also include explicit modeling and teaching of self-soothing skills when appropriate. This can occur, for example, to help the client calm down and regulate between sessions when intensely painful feelings have been evoked at the end of a session. The following subsections describe various EFTT strategies for enhancing compassionate self-soothing capacities. The most basic process is for clients to internalize the compassionate and soothing presence of the therapist over the course of therapy. This can occur implicitly or explicitly. For example, in the session following a particularly deep session, a client reported that when he had similar distressing experiences during the week, he recalled the therapist’s comforting words. Clients can be explicitly encouraged to “take my presence home with you” to help cope with distress activated between sessions. In other instances, clients can be encouraged in session to imagine how a soothing attachment figure would respond. This attachment figure could be a real person, such as a grandparent (whether alive or deceased), or an ideal or “perfect” attachment figure (whether real or fictitious). For some clients, this could also be a benevolent spiritual leader (e.g., Jesus, the Dalai Lama, Muhammad) or God. Perhaps the most evocative and powerful self-soothing strategy is for clients to recall and imagine themselves as a hurting, needy child and respond to their suffering and pain from their adult capacities. This process can spontaneously emerge in the context of other interventions, as was the case with the client Claire. After expressing anger toward her brother during IC, she quickly shifted to experiencing sadness for herself as a little girl who felt “dirty” for engaging in sexual activity. The therapist moved the empty chair closer and encouraged her to comfort herself as that little girl, asking, “What do you think she needs to hear?” Clients can also be explicitly directed to imagine themselves as adults revisiting past painful situations and consider how they might now respond. This is a component of the trauma reexperiencing and memory work that was the focus of Chapter 7. For example, the client described earlier who felt anxious about receiving a promotion at work recalled being cruelly degraded and humiliated by her father and not protected by her mother. She was asked to reenter a specific situation and imagine herself as that little girl and then consider what she could say to herself or her mother (e.g., “Help your mom be a good parent. How would a good parent talk to a frightened child?”). In this process, the client suddenly felt sorry for herself, was able to clearly articulate what she needed as a child (and as an adult), and felt entitled to having those needs met. It is important to help clients articulate and enact the exact soothing, protective responses and gestures (e.g., “You’re a great little guy— what father wouldn’t be proud of you?”) that emerge from this experience. The aim is for clients to feel the impact of this new meaning (e.g., the therapist might ask, “Imagine hearing that—what happens on the inside?”). Thus, these new soothing capacities are integrated at an experiential level.

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It is important to notice that many clients have empathy and nurturing capacities with friends and family but find it more difficult to apply these same capacities to themselves. They may find it awkward or embarrassing to “baby” themselves, believe that it is self-indulgent, or that they do not deserve such pampering. These clients have frequently grown up in environments where any signs of weakness or neediness were prohibited. This was the case with one client who deeply loved her little nephew and could easily imagine comforting him if he felt afraid or bad. She was encouraged to articulate how she would respond to him and apply that to herself in a specific painful situation. The key is to vividly evoke a poignant scene of the client’s need for comfort, ideally from the past, and then activate the related emotion scheme. Of course, for some clients, this will also involve challenging beliefs that somehow others deserve to receive comfort while they do not. For other clients whose sense of shame is deeply entrenched or who have never had an experience of nurturing, therapists may need to explicitly model these more adaptive responses. In one case, for example, a client described a childhood incident of being publicly humiliated by his mother for having his shoes on the wrong feet. He could not identify what response he would have wished for because he had no saliently positive childhood experience to draw on. Responding to this lack of experience, the therapist assumed the position of a gentle, nurturing mother (“I guess a ‘good’ mother might have said . . .”). Thus, she responded as someone who would have found her boy’s mistake funny and endearing, and she offered to help him out rather than criticize him. The client’s eyes welled up with tears, and he said, “If my mother had ever talked to me like that. . . .” The therapist acknowledged how touched her client was, and this became a shared positive attachment experience. In this way, the intervention increased the client’s awareness of an unmet need and appreciation for how important this was to him and helped him internalize the therapist’s compassionate and soothing response. The following subsection presents guidelines for implementing the standard intervention of compassionate self-soothing in EFTT, followed by a case example. Model of Self-Soothing as a Child One purpose of self-soothing is as an emotion regulation strategy to calm anxiety, fear, or distress that has been activated in session. For example, behavioral self-soothing strategies (e.g., balanced breathing, physical grounding in the present, reassuring self-talk) are used in early sessions to reduce global distress (see Figure 3.1). These strategies are distinct from compassionate selfsoothing in later sessions whereby the client expresses sorrow for their suffering. The latter procedure is typically used to transform feelings related to shame and self-blame or can be used to activate the core maladaptive sense of self so that it is fully available for transformation. Markers for the compassionate self-soothing task may occur in the context of IC; memory work; two-chair dialogues for guilt, shame, self-blame; or whenever the core sense of self emerges.

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Identify the Marker and Provide a Rationale Typically, markers for self-soothing involve the client recalling a specific situation (recent or past) in which painful feelings related to shame, self-blame, rejection, or lonely abandonment were evoked. The therapist might respond, “I hear that part of you still feels like that little boy longing for his father’s approval and always failing, believing there must be something wrong with you. That must have been so painful as a child. Let’s see if we can begin to heal that wound.” Evoke the Self as a Vulnerable, Needy Child Here, the client is encouraged to vividly imagine themself as a hurting, needy child sitting beside them or in another chair or a specific past situation. For example, the therapist might say, “Can you imagine yourself over there, as that 8-year-old boy? What does he look like?” Direct Attention to the Feelings and Needs of the Child Next, the therapist asks the client to imagine what the child is feeling and needing, providing examples as needed, ideally using the client’s own words. The therapist directs the client’s attention to personal and affective experience to deepen their emotional engagement: THERAPIST:

What do you think he, yourself as that young boy, is feeling?

CLIENT:

Something like . . . I am all wrong, not just my behavior but my whole person.

THERAPIST: All wrong as a person—so painful for a child to feel this. As

you imagine your young self there, what do you think that boy needed to feel better? CLIENT:

To feel like he was okay, such a simple thing.

Here, the therapist validated the importance of meeting such a basic developmental need. Respond to the Feelings and Needs of the Child From an Adult Perspective It is essential for the client to have access to healthy adult resources (i.e., thoughts, feelings, personal reflections, life perspectives) and respond from that adult perspective. Clients who are overwhelmed by reexperiencing their pain as a child may need more support in downregulating emotion before continuing to engage in the task. When they can engage in the task, a therapist might say, “How do you feel toward him in that situation right now as an adult, remembering how bad he was feeling? Can you give him what he needs? What do you think he needs to hear? Can you actually tell him?” This is when clients might express reluctance to be compassionate toward themselves, and the therapist can suggest imagining how they would respond to someone they care about or how a nurturing other would respond to them. This is then followed by encouraging the client to apply this same nurturing to themself.

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Experience the Effect of Soothing Response It is essential that interventions help the client deeply experience the positive effects of the soothing, comforting, nurturing response from themself. For example, “How does that feel to hear that ‘you are okay just the way you are?’” “Can you feel that in your body?” “Do you feel like it’s true?” If the client is imagining comforting another person or being comforted by another, interventions encourage them to imagine how the other would feel or how they would feel receiving this from the other person. Carry Into the Present Finally, the interventions bridge to the client’s current life so they can reexpe­ rience this compassionate self-soothing in times of distress when old painful feelings and messages get activated. If the client imagined soothing another person, the therapist can ask them how they might apply that to themself. This task also creates a formal reference point, a touchstone that therapists and clients can refer to in subsequent sessions when and if the need arises. Case Example of a Compassionate Self-Soothing Intervention This case example (Paivio, 2015) illustrates the use of the self-soothing procedure to first activate emotional pain and deepen experiencing and then access sorrow and compassion toward the self. “Maureen” had a history of multiple types of traumatic experiences (physical, emotional, sexual abuse, traumatic loss) and abuse at the hands of multiple perpetrators beginning in childhood and continuing through her adult relationships. Her core sense of herself was that of being irrevocably “damaged.” Maureen’s storytelling style was externally focused (i.e., low-level experiencing). She told the details of the many tragedies she had experienced in a matter-of-fact way, and she was minimally responsive to the therapist’s empathic responses intended to direct her attention to internal experience. These were markers for the therapist to try to deepen the client’s emotional experiencing so that her storytelling became more personal and affective. Therefore, the self-soothing procedure was used initially to evoke emotional experience and then later to specifically elicit nurturing and compassion toward herself. This work with Maureen required considerable validation of her difficulties with emotion and emotion coaching, guidance, and direction to help her emotionally engage in the task. Maureen could easily imagine herself in the chair across from her as a little girl with long blonde hair and freckles. But when asked, she was unable to access feelings toward herself or identify her needs as a child or even those of her own children if they were hurting. CLIENT:

That’s the problem. I don’t know that [what her children would need to hear] because I feel I’m not a very emotional person; I’m more a matter-of-fact person.

THERAPIST: Okay, so that is another thing that kind of got squashed . . .

[validation, identify the problem]

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CLIENT:

Yes, I’m not a nurturing kind of person or show much emotion; I’m more a concrete thinker. So, I don’t know what I would say.

THERAPIST:

What do you think she needed, Maureen, that little blonde girl? Do you think she’s sad? Wanting someone to love her? [Client: Definitely, yeah] Love her; tell her she’s smart, pretty? [evocative empathy, providing suggestions]

CLIENT:

Mm-hmm. I kind of believe that even back then, she felt like this is what her life was supposed to be.

THERAPIST:

So, what can you tell her that would help improve things?

CLIENT: [pause] I don’t know. THERAPIST: She thinks this is what my life is supposed to be; it’s never

going to get better. CLIENT:

Unfortunately, it didn’t; it didn’t get any better [gently laughs, tears emerge]. It was just a life of coping.

THERAPIST: What are you feeling? Sad, yes. [attuned to client tears] So,

you’re saying, “I’m sorry, Maureen, that you had just a life of coping.” Can you tell her what you would have liked her to have? [stroking the other chair] What did she deserve? You deserved . . . CLIENT: [internal focus] You deserved—definitely—happiness. THERAPIST:

Happiness, fun, carefree childhood, innocence.

CLIENT:

Innocence, yeah, because that was taken away, gone by the age of 5.

THERAPIST:

So, you deserved all these things, Maureen. . . .

CLIENT:

Yeah, she did.

THERAPIST:

Can you say YOU did, “you did,” Maureen?

CLIENT:

You deserved, definitely [Therapist: Definitely.] much more happiness, less weight on your shoulders, less problems.

THERAPIST:

You didn’t deserve all that crap. You deserved a decent life.

CLIENT:

Yeah, I didn’t deserve all the struggles. But I’m gonna make it better. I’m working on it for you. We’ll live through our children, be happy through them.

THERAPIST: Okay, that will bring us some joy—start there anyway, then

maybe soak some of it in for yourself. That’s my wish for you. [compassion and genuineness]

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In the example, therapist validation and acceptance of the client’s difficulties in working with emotional experience, together with guidance, helped deepen her emotional engagement and experiencing step by step. This, combined with therapist modeling, was instrumental in accessing the client’s sorrow and compassion toward herself. At the end of the session, Maureen expressed deep appreciation for the experience, which opened her heart to a new way of relating to herself.

DIFFICULTIES WHEN WORKING WITH FEAR AND SHAME In this section, we present strategies for addressing common difficulties clients may have with the interventions for addressing fear (previous chapter) and shame (this chapter), particularly in the context of using two-chair enactments. No Contact Between Parts of the Self When clients continue to have difficulty maintaining contact between the parts of the self in two-chair enactments despite clear directives, therapists must first collaborate with them to understand the reason for this difficulty. It could be due to structuring problems, lack of clarity about the task, performance anxiety, or a client’s need for direct relational contact with the therapist. Again, as with variations of the IC procedure, optimal EFTT intervention means providing as much support and contact with the therapist as the client needs. The intervention principles underlying two-chair procedures are used almost identically, even in cases when most of an inter­action is directly with the therapist. In these instances, only pivotal statements that indicate the emergence of healthy new experiences are directed at the other chair. To maintain contact with “hot” processes, this is done quickly, without an elaborate rationale and without physically moving the client to the other chair. No Conflict Between the Two Parts of Self There are two common difficulties when trying to maintain the dialectical tension between two parts of the self. One difficulty is lack of activation—the two-chair enactment never really takes off (and this is not due to technical difficulties). The other is when the client “agrees” with the dominant part of the self, and there no longer is a split. In both instances, intervention requires the reactivation of the enactment and conflict. The goal is to increase the emotional impact of messages from the dominant self. This is accomplished by specifying and intensifying those negative messages. The contempt of the critic, for example, must be directed at the more vulnerable self to elicit a reaction (e.g., the client says [as self-critic], “You need to be accepted so badly that you’re blind to reality!”).

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The Therapist Is Reluctant to Activate Painful Feelings This difficulty applies to two-chair enactments for self-criticism, self-soothing procedures, and memory work. Therapists who are reluctant to promote and intensify distressing feelings, particularly feelings of shame, tend to focus instead on changing these feelings. However, because change in EFTT is contingent on evoking core maladaptive emotion structures, the client must feel afraid, dirty, or unlovable in the session. This problem is a bit like looking for solutions before one has a clear experience of what the core problem is. Furthermore, EFTT requires a therapist stance of exploration rather than a focus on change. Exploration requires trust in the client’s healthy processes. This trust is based on knowledge, training, clinical experience, and an assessment that the client has healthy internal capacities that can be fostered toward change. Caution regarding the intensification of emotional pain is necessary when clients have histories of severe affect dysregulation with a risk of self-harm. Intervention in these cases requires gradual engagement, monitoring the client’s level of distress, and integrating regulation strategies when indicated. The Client Directs Extreme Hostility Toward the Self in a Two-Chair Enactment It can be especially alarming when a client directs extreme hostility at themselves and then feels destroyed by the hostility, agrees with it, or both. Again, the purpose of increasing anger, contempt, and disgust toward the self is to increase a client’s awareness of the damaging effects these emotions have when directed at the self, how much they hurt, and the client’s agency in eroding their self-esteem. This experiential awareness is thought to activate a self-protective response that reduces the pain and transforms shame. However, it is also not appropriate to promote or encourage the client’s self-destructive tendencies, just as it is not appropriate to intensify rage at others. So, therapists are continually assessing how devastating the criticisms are and whether there is potential for softening. When there is little room for a dialogue between parts of the self (i.e., no give and take), memory work, presented in Chapter  7, is preferable. Just as interventions are used to shift aggression to more assertive expressions of anger, when extreme hostility is directed at the self, it is appropriate to acknowledge negative feelings but reduce rather than increase arousal. In two-chair dialogues, for example, interventions can direct the client to specify their perceived defects and focus more on feelings from the more vulnerable part of the self. If hostility does not decrease, the therapist needs to explicitly tell the client that self-destructive hostility directed toward the self is not healthy and then collaborate to change it. The therapist can switch to empathically exploring the client’s hostility toward the self or can reframe the purpose of the enactment—for example, Okay, but this isn’t about true and false, is it? Who’s right or not? The point is, how does being on the receiving end of that kind of criticism make you feel? It must leave you feeling so . . . what? Hurt? Squashed? You seem so deflated, so crushed down.

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Orienting toward the vulnerable experience highlights an unmet need, which then leads to more adaptive activation. Here, again, it is useful to differentiate EFTT intervention (“what this criticism does to you”) from CBT interventions that encourage clients to examine the evidence for and against a belief. Once clients can allow painful experience, feel more self-confident, and be less self-blaming, they are better able to express feelings and needs to imagined perpetrators. This marks the transition to Phase 3 of EFTT, which is the focus of the next few chapters.

10 Resolution of Interpersonal Trauma Through Adaptive Anger

T

he preceding chapters dealt with strengthening clients’ sense of self by helping them work through fear, avoidance, and shame during Phase 2 of emotion-focused therapy for trauma (EFTT). This is necessary before clients can hold offenders accountable for harm, fully grieve losses, and thereby resolve their issues with offenders and attachment figures. This chapter marks the beginning of Phase 3 of EFTT, which is defined not by a particular session number but by establishing a more sustained focus on resolving interpersonal issues. As such, we open this chapter with a brief review of theory and research related to the resolution of trauma. After that, the lion’s share of this chapter focuses on anger. This is because the catalyst for resolution in this phase is full experience and expression of previously inhibited adaptive anger at maltreatment and sadness at loss, which lead to meaning exploration and change. Once these emotions are accessed, the process of resolution typically moves forward relatively quickly; this arousal and resolution phase of therapy may take only a few sessions. To that end, we describe research supporting the benefits of healthy anger expression and intervention principles and strategies, first for reducing maladaptive anger, then for accessing adaptive anger in response to maltreatment during the imaginal confrontation (IC) procedure.

https://doi.org/10.1037/0000336-011 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  235

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REVIEW OF THEORY AND RESEARCH ON THE RESOLUTION OF INTERPERSONAL TRAUMA All treatments for complex trauma recognize that repeated betrayal and maltreatment at the hands of caregivers and loved ones cause a more complex array of disturbances than exposure to a single traumatic event (Ford & Courtois, 2020). EFTT is a distinct treatment approach in its emphasis not only on reducing current symptom distress and self and interpersonal problems but also on resolving past issues with specific attachment figures (and offenders) that continue to be sources of distress. EFTT Definition of Relational Trauma Resolution Resolution of relational trauma in EFTT involves developing increased emotional competence and more adaptive views of the self and specific others (i.e., perpetrators) who are the focus of therapy. More adaptive emotional processes include reduced negative feelings concerning the other (e.g., hurt, fear, shame, anger, sadness) and an increased ability to acknowledge and attend to one’s needs. When the client continues to be in a relationship with past offenders, it could also mean letting go of the hope that these individuals will meet their needs (e.g., attention, approval, respect) and letting go of expectations that the other will acknowledge responsibility for harm, apologize, or change. However, clients do not give up on their own needs but rather find alternative ways to meet them. Resolution also includes increased self-esteem, despite the other’s opinions. It involves reducing the self-blame for one’s victimization and an increased ability to assert and stand up for oneself. Overall, there is a growing detachment or increased separation from the other and the traumatic events. Changes in client perceptions of the other include a shift from globally negative views of the other (the “bad object”) to a more differentiated and realistic perspective, a better understanding of the other’s position and actions toward the client, and clearly holding others responsible for the harm they have caused. The client may or may not feel more positively toward the other or feel forgiving. The relationship between resolution and forgiveness becomes important here and is discussed in the following section. Resolving issues in relationships with attachment figures and forging a strong therapeutic relationship generalizes to reduced symptom distress, increased self-esteem, and reduced general interpersonal problems. These changes help cultivate or restore the capacity for interpersonal connectedness that all too often was shattered by the trauma. This definition of resolution in EFTT shares features with the construct of posttraumatic growth (Tedeschi et al., 2018). According to this idea, after struggling to come to terms with traumatic experiences, people report personal growth that exceeds their pretrauma levels of functioning. Thus, out of the devastation of trauma, there is the possibility of constructing something new. These new (rather than recovered) benefits include increased personal strength, greater clarity about values

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(e.g., the importance of relationships), closer connections with family and loved ones, and a generally stronger sense of spirituality or personal meaning in life. The process of interpersonal resolution in Phase 3 of EFTT develops from the process of clients fully acknowledging the damage and harm that has been done to them and identifying the cause of damage and the person(s) responsible (e.g., “His rages terrified me, destroyed my mother, ruined our family, made me take on a responsibility for the family that was way beyond my years”). This can be accomplished only by allowing and fully expressing feelings of anger and sadness about the other and traumatic events (e.g., “I hate him for what he did to me and my mother,” “I feel so sad that we all missed out on so much”). In EFTT, this occurs in the context of the IC procedure (or alternative) whereby clients directly (or indirectly) confront imagined perpetrators of harm. The Question of Forgiveness The construct of forgiveness in EFTT overlaps with but is not identical to resolution and is particularly relevant to resolution through anger. Facilitating forgiveness is controversial partly because it sometimes comes with moral and religious imperatives that may seem distasteful to some individuals. It is also unclear whether forgiveness is appropriate in situations of extreme cruelty and childhood abuse and whether forgiveness, as a therapeutic outcome, affords additional benefits beyond other forms of resolution (Chagigiorgis & Paivio, 2006). In any case, forgiveness does not involve condoning the behavior of offenders and bypassing anger but rather acknowledging offenses and working through anger. Widely held definitions of forgiveness suggest that it requires both psychological separation from and increased affiliation with offenders. An analysis of posttherapy interviews with clients in EFTT indicated that although most clients (82%) reported resolving issues with perpetrators, only a small portion (23%) of those who resolved their issues also reported forgiving the perpetrators (Chagigiorgis & Paivio, 2006). This is consistent with findings from a study of emotion-focused therapy for the forgiveness of “emotional injuries” using the empty-chair intervention (Greenberg et al., 2008). Even in that study, with a nonclinical sample that explicitly aimed at forgiveness, less than half of clients actually forgave offenders (more “let go” of their anger). In EFTT, specifically, clients more often forgave neglectful as opposed to abusive others (Chagigiorgis & Paivio, 2006). These neglectful others tended to be nonprotective mothers. As a case in point, recall that the client Monica was able to forgive her dead mother by the end of therapy. This suggests that clients may be more motivated to forgive primary attachment figures. This also could be a function of more time spent on task because more time in treatment was spent focusing on issues with primary attachment figures (e.g., as opposed to estranged abusive fathers or nonfamily members). Research on forgiveness also indicates that people’s motivation to forgive is a function of

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many factors, including religious or moral beliefs and the belief that forgiveness will reduce personal distress (for a review, see Chagigiorgis & Paivio, 2006). Moreover, clients in emotion-focused therapy for couples were more likely to forgive a romantic partner when they believed that partner truly regretted and felt shame about the transgressions (Woldarsky Meneses & McKinnon, 2019). This finding likely also applies to forgiveness of perpetrators in EFTT. Therefore, as noted earlier, EFTT does not advocate forgiveness as a treatment goal but rather leaves this up to the individual client. If forgiveness of the other has been an appropriate and desired goal for the client, this issue will surface again during Phase 3 of therapy as the client moves closer to resolution. Issues of forgiveness also could emerge for the first time during this phase as perceptions of self and other evolve. In either case, tracking clients’ perspectives on this issue may be a key part of the resolution process. The Process of Interpersonal Trauma Resolution in EFTT The process of interpersonal resolution in EFTT is based on steps in the model introduced in Chapter 6 and presented in Figure 6.1. This resolution process also parallels the general process of change shown in Figure 3.1 of Chapter 3. In both these figures, we see that pathways to resolution and change are through anger and sadness or grief, which is the focus of the next chapter. Full expression of adaptive anger in EFTT occurs following the reduction of fear and shame (the focus of Phase 2 and the preceding chapters). At the emergence of adaptive anger, clients are encouraged to reengage in the IC (or evocative exploration) procedure and express anger directly to the imagined other. Again, the relatively uninhibited expression of adaptive emotion to imagined offenders marks the shift into Phase 3. Although resolution through anger does not necessarily occur before grieving losses, the strength that comes with anger frequently helps clients face the vulnerability of sadness and loss.

ANGER AND TRAUMA ACROSS THEORETICAL PERSPECTIVES There is abundant literature documenting the centrality of anger in trauma. Anger at violation and maltreatment is a healthy emotion that motivates selfdefense but becomes problematic when it is overgeneralized, underregulated, used to cover more vulnerable emotional experience, or turned against the self. Because areas of the brain responsible for affect regulation develop in the context of secure attachment relationships, failure of brain development may account for the hair-trigger anger response observed in many survivors of child abuse trauma (Schore, 2003). Anger and aggression are also learned responses and ways of coping. There is considerable evidence supporting a link between both childhood physical abuse and exposure to violence with aggressive behavior later in life (Wolfe, 2007). Anger dysregulation is a particular

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problem among war veterans who have been exposed to prolonged and extreme violence (Novaco & Chemtob, 2015). Dysregulated anger is also a feature of borderline personality disorder that is associated with a history of childhood abuse. Promoting the experience and expression of anger in therapy is controversial. Anger is a powerful emotion, and when accompanied by aggressive behavior, it can have destructive personal, interpersonal, and societal consequences. Moreover, most research has demonstrated that although increasing anger arousal (venting or catharsis) can produce immediate relief, it does not reduce anger in the long term (Fernandez, 2016). Therefore, with few exceptions, reducing maladaptive anger is the focus of most approaches to trauma therapy when anger is identified as a problem (e.g., Linehan, 2015; Novaco & Chemtob, 2015). However, some recent cognitive behavior therapy (CBT) approaches to therapy for complex trauma (e.g., Jackson et al., 2020) also acknowledge fear of anger as a problem. These approaches also include training in emotion awareness and assertive communication skills. However, EFTT distinguishes among different types of anger and specifies criteria for adaptive anger experience and expression, as well as the circumscribed parameters under which anger intensification in therapy is appropriate. Criteria for the healthy expression of adaptive anger in EFTT (described later) are compatible with principles that would be applied in CBT assertiveness training (e.g., Linehan, 2015)—even if those treatment theories do not explicitly differentiate between different kinds of anger. When researchers examined the benefit of skills training in dialectical behavior therapy for borderline personality disorder, they found increases in assertive anger (rather than a reduction in anger, per se) mediated the benefits of treatment (Kramer et al., 2016). This finding is consistent with EFTT theory. However, to promote these adaptive emotional experiences, EFTT focuses more on exploring the personal meaning of disavowed anger than on the behavioral aspects of skills training. Traditional psychodynamic approaches also focus on the meaning associated with defensive anger, or “anger turned inward,” and help clients acknowledge the underlying feelings or express anger at the appropriate source. Meanwhile, intensive short-term dynamic psychotherapy (Abbass & Town, 2013) emphasizes increasing arousal to increase awareness of suppressed anger and unconscious impulses. EFTT includes anger intensification strategies under specific conditions—increasing arousal is only appropriate for accessing inhibited adaptive anger to access the associated adaptive information. Paradoxically, a healthy anger experience can sometimes facilitate forgiveness. For example, Monica had been unable to forgive her mother, who had committed suicide, largely because Monica’s anger at her mother had been invalidated and suppressed for so many years. Once one’s anger has been acknowledged, validated, assertively expressed, and understood, people feel stronger and more self-confident, and they are freer to focus on, empathize with, and forgive others. Several research studies support the benefits of adaptive anger expression in EFTT and similar approaches. First, indirect support comes from outcome

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and process–outcome studies that support the treatment model, in general, with its emphasis on adaptive anger expression (Paivio et al., 2010; Paivio & Nieuwenhuis, 2001). Similar results have been reported for comparable emotion-focused therapies for other disorders (see Greenberg & Goldman, 2019a) in which expression of inhibited anger is a key therapy process. A host of emotion-focused therapy process studies on a range of treatment concerns have used observational methods to track healthy assertive anger and shown that it predicts symptom reduction post-session and at the end of treatment (PascualLeone & Kramer, 2019). One of those studies specifically examined EFTT and showed that when a client’s expression of assertive anger—among other primary adaptive emotions—increased over the course of therapy, it more than doubled the likelihood of good treatment outcome (Khayyat-Abuaita et al., 2019). Direct support for the benefits of anger expression comes from studies that specifically examined the role of anger in EFTT. In one study (Holowaty & Paivio, 2012), 50% of the episodes identified by clients as helpful had anger as the most predominantly expressed emotion (followed by sadness, fear, and shame). Furthermore, results indicated that emotional arousal was significantly higher in helpful episodes than in a group of control episodes. Another study found that higher arousal during both IC and evocative exploration predicted the outcome in EFTT, and again, the dominant emotion during these episodes was anger (Ralston, 2006). Furthermore, anger expression in EFTT does not appear to be simply a function of clients’ compliance with their therapists’ directives and the treatment model. At pretreatment, 64% of clients identified anger-related problems among the three target complaints they wanted to address in their therapy. Of these, the most frequently identified were unresolved anger toward perpetrators of abuse and difficulties stemming from limited access to anger experience (e.g., powerlessness, nonassertiveness). Thus, many victims of complex trauma entered therapy with a limited capacity to access anger and its associated healthy strivings. Another study examined the contributions of anger expression specifically in the resolution of child abuse trauma in EFTT (Paivio & Carriere, 2007). Client dialogues during the IC procedure were analyzed using criteria for healthy anger expression. The results indicated a moderate relationship between healthy anger expression and the resolution of abuse issues and interpersonal dimensions of change, particularly at 12 months after treatment. Together, these results support the beneficial effect of healthy anger expression during IC on treatment outcome in EFTT, particularly on interpersonal dimensions of functioning.

PROCESS DIAGNOSIS: DISTINGUISHING DIFFERENT TYPES OF ANGER Anger is a powerful emotion that has a profound influence on self-organization and interpersonal relations. There are important societal implications concerning displays of anger and its connection to aggressive behavior that account for the existing emphasis in the literature on anger regulation (Sturmey, 2017).

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Anger involves surges of adrenaline; a loud, firm voice; erect body posture; and direct eye contact with the target, all of which ready a person to thrust forward and attack. Adaptive Anger The following subsections describe anger that has an adaptive function and specify criteria for healthy anger expression in therapy. Primary Adaptive Anger Like other basic affects, adaptive anger is an immediate and direct response to real threat or infringement in the environment that is not preceded or mediated by obvious cognitive or other affective components. Anger at interpersonal violation and maltreatment quickly mobilizes self-protective resources and action. It provides energy and a sense of power that readies the individual for self-defense or to protect one’s integrity and boundaries. Interpersonally, anger signals others that an offense has occurred, creates separation and distance, and signals them to back off. Difficulties here concern modulating the intensity of anger, which can result in either dysregulation (i.e., too much anger) or overcontrol (i.e., too little anger, when it would be appropriate and adaptive). In either case, the information associated with the anger experience is unavailable to guide adaptive action. The negative consequences of overwhelming anger are obvious. Negative consequences of anger avoidance include a pervasive sense of victimization, recurrent bouts of depression, difficulties with assertiveness, and problems with establishing appropriate interpersonal boundaries. Chronic suppression of adaptive anger can also result in hypertension and instances of “bottle up–blow up” such that the tension of repeated suppression eventually results in explosive outbursts of anger that are disproportionate to the situation (Novaco & Chemtob, 2015). Criteria for Healthy Anger Expression EFTT defines healthy anger expression according to specific criteria that are consistent with the definition of primary adaptive emotion (Greenberg & Paivio, 1997; Paivio & Carriere, 2007; Pascual-Leone, 2018). These criteria inform and guide interventions intended to promote anger expression—for example, when confronting perpetrators of harm during IC. Criteria for healthy anger expression are as follows. First, the anger must be directed outward toward the perpetrator rather than inward toward the self, and it must concern actual and specific harms, transgressions, or violations. As a guideline, if it is unclear what the angry client is fighting for and what unmet needs are being asserted, it is probably not a healthy expression of anger. Second, the anger must be differentiated from other emotions, such as sadness, guilt, or fear. Anger expression mixed with tears or fear, for example, does not allow the individual full access to the cognitive, motivational, or somatic information specifically associated with the anger experience. Third, the anger is expressed assertively with the ownership of experience rather

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than aggressively, passively, or indirectly. For example, clients use “I” statements rather than referring to themselves in the third person or blaming and complaining or attacking or hurling insults at others. Anger that is inappropriately expressed does not have the desired effect on the environment, and consequently, adaptive needs for respectful treatment or distance are not met. Fourth, the intensity of anger expression must be appropriate to the situation. Intense emotional expressions that are a catalyst for change are not the same as catharsis, although relief and release of tension can play a role. Appropriate intensity is assessed through verbal and nonverbal indicators of arousal, including body posture, vocal quality, and facial expressions congruent with anger and the situation. Inappropriate anger intensity includes both rage that is overwhelming and anger that is lacking in conviction or energy. Again, in both instances, the associated adaptive information is neither available to guide one’s action nor a clear social message of assertion communicated to others. Finally, anger expressions must include some elaboration and exploration of meaning. Healthy anger is not a verbal tirade but rather involves working with anger to understand it. This is consistent with the fundamental principle underlying EFTT that client experiencing is the primary source of new information used in promoting resolution and change. Problematic Anger Most therapeutic approaches focus on reducing maladaptive anger but typically do not distinguish among subtypes. However, distinct kinds of problem anger require different intervention strategies (Pascual-Leone et  al., 2013). The following subsections describe clinically relevant distinctions among subtypes of problematic anger. Primary Maladaptive Anger Most forms of maladaptive anger are inappropriate to the situation and long lasting rather than immediate, fleeting responses to specific violations. Primary maladaptive anger is an immediate but overgeneralized response to a perceived environmental threat and is frequently associated with posttraumatic stress reactions. A rape victim, for instance, might react with rage at being touched by men; a survivor of child abuse, whose trust has been betrayed, might react with anger to others’ displays of affection. In many ways, primary maladaptive anger is a characterologically entrenched style of responding that now undermines effective functioning. Secondary Anger Secondary anger is a response to maladaptive cognitions that produce, perpetuate, or escalate the anger (e.g., erroneous attributions of malicious intent or dwelling on revenge fantasies). Alternatively, secondary defensive anger masks more vulnerable core emotions, such as sadness, fear, or shame. Obvious examples are anger and aggression in response to the shame (i.e., humiliation fury) or fear of abandonment (i.e., the rage of desperation), as observed in

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some clients with borderline personality disorder or some male perpetrators of intimate violence. In these instances, secondary anger serves the maladaptive function of momentarily alleviating painful feelings of vulnerability, and this is reinforcing when it is repeatedly successful. Instrumental Anger When anger is used, consciously or unconsciously, to manipulate or control others, it is instrumental. Thus, the social impact of angry, aggressive behavior can act as a means for attaining a desired interpersonal goal (i.e., control). This, too, can be a reinforcing pattern of behavior. Aggression without affect is a similar but more highly antisocial behavior, although even people without personality disorders are susceptible to the instrumental function of anger. Complexity of Anger Processes The same individual can experience and express different types of anger. The complexity of anger experience and its accurate assessment are illustrated in the client Paul, who was described in earlier chapters. He had been physically abused by his father and sexually molested by a male relative, and he frequently experienced adaptive anger and secondary defensive anger covering shame. Paul also had a history of using anger and aggression to control others and prove his masculinity. Moreover, he often felt betrayed and insulted by his wife and held cultural beliefs that children should respect their parents, blowing up at perceived signs of disrespect. Finally, he also had difficulty acknowledging feelings of anger about his father’s abuse because he feared this would jeopardize their current relationship, which he had worked so hard to achieve. Each of these distinct anger processes required different intervention strategies. Feelings of contempt and disgust also are related to anger experience. Like anger, these are maladaptive when directed at the self (as discussed in the preceding chapter) but can be adaptive when directed at others in response to legitimate moral transgressions and despicable behaviors (e.g., sexual abuse). Contempt involves looking down on an object with a sneer or curled lip of disdain (“You worm!”), whereas disgust involves wanting to rid oneself of the object by revulsion or throwing up (“You make me sick!”). Although similar principles apply, accurate intervention with anger, contempt, and disgust involves accurate perception and empathically responding to the nuances in meaning associated with these different emotions.

INTERVENTION PRINCIPLES Many of the intervention principles discussed in earlier chapters also apply to working with anger. In the following sections, we present examples of the specific ways these principles are implemented in the context of this specific emotion.

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Regulation Clients may inhibit their legitimate anger toward abusive or neglectful others for a variety of reasons, including fear of losing control, fear of being like the offender, or concern about unfairly blaming the other. In these cases, EFTT interventions validate client concerns and, at the same time, promote acknowledgment of legitimate angry feelings and model, shape, and teach appropriate and assertive expression of these feelings. However, anger that is underregulated does not serve an adaptive function, even if the anger itself is a legitimate and adaptive response to harm. High levels of arousal overwhelm both the angry individual and the person being confronted with that anger. As emotional arousal increases, the specificity of meaning the client can attend to deteriorates, so what may have been productive loses its focus (Pascual-Leone et al., 2013). Similarly, chronic defensive anger covering a more vulnerable experience of hurt, sadness, or shame cuts the person off from the information associated with that more primary experience.

Gradual Engagement When clients are afraid of, deny, or believe that anger is socially unacceptable, the change principle resembles that of gradual exposure to or engagement with threatening experience. Intervention involves successive approximations of the experience (e.g., moves from “I don’t like . . .” to “feeling annoyed or resentful” to “feeling angry” to “feeling outraged and furious” at the extreme end). When clients deny feeling angry at situations that normally would evoke anger, therapists must use empathic responses, questions, or challenges to elicit a reaction or open a door for acknowledging the experience (e.g., “Sounds like you thought that was pretty unfair,” “Did you like what she did?” “I would have been so pissed off!”). Here, clients are also implicitly learning the range and appropriate modulation of anger experience, where lived experience helps to challenge maladaptive beliefs that all anger is dangerous. At other times, intervention can focus on client actions that emerge spontaneously and then encourage them to put words to these actions (e.g., “What does that type of voice say—’how dare you’?”). Similarly, a therapist might ask the client to put words and meaning to their body posture, as in “I notice your fist is clenched as you speak. . . . Can you put words to that?” Secondary emotions that cover anger (e.g., guilt, fear, defeat, helplessness) are bypassed or implicitly discouraged by making selective reflections. Instead, the therapist validates and supports the client’s authentic, spontaneous expression of anger at injustice, unfairness, or maltreatment. A good example of gradual engagement with anger is in the client John, presented in previous chapters, who, following the death of his mother, was sent to an orphanage where he was physically and sexually abused. Initially, he was completely resistant to acknowledging any anger about his life experiences. Intervention first needed to explore the client’s resistance (“It isn’t

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‘Christian’ to be angry . . . I just want to be a good person”), then educate him about anger, and eventually used successive approximations to help him acknowledge his anger. THERAPIST:

When you think now about those things [beatings, sexual molestation] happening to other young boys, like maybe your nephew, how do you feel?

CLIENT:

Well, I don’t like it. It bothers me.

THERAPIST: I’m sure it does. Can you stay with that? Say more—what

bothers you about it? Eventually, John was able to say that the abusive priests in his residential school “shouldn’t have done what they did; it wasn’t right. They are to blame for all the emotional problems I’ve had.” He was able to acknowledge his anger at “the system” for putting him in an orphanage and depriving him of his family and Indigenous culture and his anger at individual priests for abusing him. Anger expression, especially toward parents, also is prohibited in certain cultures. In many Asian cultures, for example, strong social norms exist about respecting parents and elders. In these instances, intervention involves education about the role of adaptive anger, validating the client’s desire to be respectful, and distinguishing parental intentions to discipline and wanting the best for their children from what crossed the line into cruelty and abuse. For example, the therapist might ask, “Do you think he had your best interests at heart?” The principle of gradual engagement is relevant here—from “It was not right,” “It was too extreme,” “It was cruel” to “I hated it,” “I did not deserve that,” to “It was abusive.” The actual label of “anger” is not as important as generating sufficient arousal to activate the emotion scheme and associated adaptive information. For example, one client of Chinese heritage felt uncomfortable using the word “anger” during IC with his rageful, harshly critical father. His confrontations during the procedure were initially measured and controlled and focused on “correct” assertive communication. The therapist validated his discomfort and provided information about “healthy anger” (vs. his father’s “rage”) and explicit directives for engaging in IC (“This is not about the perfect response. What do you really feel inside imagining him railing at you like that? What do you want to say—from your gut?”). The client immediately said to his imagined father, “Back off! Leave me alone!” The therapist helped him elaborate on this response (“Say more; tell him what is so toxic about his behavior”) and eventually set boundaries (e.g., “What are you willing or not willing to put up with from him, your ‘line in the sand?’”).

Explore Secondary Anger Secondary anger typically needs to be changed. On the one hand, anger generated by maladaptive thought processes is changed by accessing, exploring, and

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restructuring these maladaptive cognitions. Thus, working with secondary anger can have a more rational or cognitive intervention style (i.e., “But is this really working for you?”). On the other hand, if possible, changing anger that masks more vulnerable feelings is best accomplished by simply bypassing the angry, blaming reaction. This is because the goal ultimately is to access more core emotional experience and associated information as quickly and efficiently as possible. When defensive anger cannot be easily bypassed, it needs to be explicitly explored again to access core primary experiences. The client who routinely expresses anger at signs of interpersonal slight, for example, needs to gain awareness of the underlying feelings of hurt, rejection, or sadness that likely give rise to the defensive anger. Identify the Instrumental Function of Anger Appropriate intervention for instrumental anger involves confronting and interpreting the instrumental function of this anger and teaching more adaptive ways of getting one’s needs met. Both secondary and instrumental anger can be problematic at the level of intensity, and, in this case, intervention needs to include teaching anger regulation strategies. All the types of anger can be problematic at the level of chronicity or frequency, such that anger might be the dominant emotion some clients experience or express. These individuals typically have limited awareness or experience of other (subdominant) feelings, and therapeutic intervention requires emotion awareness training. This consists of empathic responses that direct client attention to and help them accurately label their other feelings. It can also can include structured exercises that explicitly teach emotion awareness skills (see Linehan, 2015). In many ways, instrumental emotion is addressed by reflecting on the narrative and social context of the client’s emotional experience—for example, their need to control or overpower others in their life to ensure that their wants and needs are met (Pascual-Leone, Paivio, & Harrington, 2016). Symbolize Meaning Through exploring the experience of anger, clients come to understand their anger—its associated values and needs, the effects maltreatment or injustice has had on them, perceptions of self and offending others, and so on. This new information is used to construct new personal meaning. In cases of maladaptive or secondary anger, the maladaptive meaning (e.g., misattributions of hostile intent) can be examined and modified.

INTERVENTIONS FOR CHANGING MALADAPTIVE ANGER The following subsections describe EFTT’s approach to reducing maladaptive anger, beginning with reducing dysregulated anger and aggression.

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Regulating Anger Before turning our attention to the process of resolving interpersonal trauma through the promotion of healthy anger experiences, it is important first to clarify what types of anger not to promote and how to work with them. As noted earlier, chronic and underregulated anger are frequently associated with exposure to trauma, particularly complex interpersonal trauma. Problems with anger dysregulation and associated aggressive behavior can be difficult to change (Novaco & Chemtob, 2015; Pascual-Leone et al., 2013) because they might be reinforcing and part of the individual’s personality style. Just as in recovery from phobia, neural pathways never completely disappear, but motivated clients can carve out more preferred pathways, and old responses can fade with time and disuse (Lane & Nadel, 2020; LeDoux, 2012). Maladaptive anger interferes with interpersonal trauma resolution; the client is stuck in an earlier stage of emotional processing, characterized by hostile blaming and rejecting anger (refer to Figures 3.1 and 6.1). Although EFTT has an affinity with CBT strategies with respect to this area, EFTT is not an anger management therapy. Rather, strategies for regulating or reducing this type of anger must be integrated into the resolution process; it should be part of the personal meaning-making process, not an isolated skill for reducing the intensity of a specific emotion. In many instances, it will be more important for clients with chronic anger problems to focus on grief and sadness expression (instead of anger) as a route to the resolution of complex trauma. However, the dilemma is that anger in response to injustice, violation, and maltreatment also has legitimacy and should not be avoided. Therapy must validate clients’ experiences of adaptive anger and find ways to help them express it appropriately. Moving Beyond Secondary Anger The first step in working with chronic anger in EFTT is assessing the client’s capacity to attend to and identify the internal experiences associated with anger and the factors (internal and external) that contribute to escalating and perpetuating anger. Limited awareness must be increased for clients to gain control of their anger experience (e.g., the therapist might say, “So, when you think your kids don’t respect you and dwell on that; you feel yourself getting more and more angry”). The next step is to help clients distinguish between different types of anger experience, so they know when to accept, express, modulate, or bypass their anger and attend to more core vulnerable experience. If necessary, intervention will include strategies for downregulating emotion, such as breathing, relaxation, time-out, or distraction, that have been well articulated in the CBT literature. Memory evocation strategies, such as those described in the preceding chapters, can be used to help clarify the triggers for problematic anger reactions. In instances of secondary anger, the underlying cognitive–affective processes need to be brought into awareness and maladaptive aspects changed. Of course, EFTT characteristically

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focuses more on exploring meaning than directly challenging maladaptive cognitions (e.g., the therapist might ask the client, “What’s that all about, this sense that disrespect from your teenage kids is so intolerable?”). Anger at perceived disrespect, as in the case of Paul, discussed earlier, also could be understood as a defense against hurt or shame, in which case the therapist directs client attention to the core experience (e.g., “So it triggers some sense that you’re a bad father, incompetent? That must hurt a lot. Let’s stay with that; it’s important”). In terms of confronting offenders in the IC procedure, anger intensification is avoided with clients who have a history of problems with anger control. However, the therapist models and sometimes directly teaches appropriate assertive expression skills, using the guidelines for healthy anger expression presented earlier. For the client whose dominant emotion is anger, resolution of past trauma will include acknowledging appropriate anger at abuse, but resolution may largely occur through accessing hurt and sadness, which is less available. An example of this is Paul, who had a history of anger and aggression problems. He recognized that his violent father had been a bad role model and that he, himself, used anger to feel powerful and control others. He was motivated to change this behavior but still was quick to anger, and anger experience initially dominated therapy sessions. Early in therapy, the therapist observed that Paul’s anger dominated and threatened to derail the therapy process. She collaborated with him on shifting this focus from anger to accessing more vulnerable feelings. Paul was able to attend to his internal experience and had learned strategies for deescalating anger arousal, so he was able to explore the thoughts and feelings that contributed to his anger and its escalation. Different types of anger and underlying vulnerable experience were identified and explored as they emerged in sessions (“hot” processing). Over time, the client allowed himself to be vulnerable with the therapist. Resolution of past trauma finally involved the client acknowledging his contribution to his pain through maladaptive anger and grieving the many losses he had endured. In particular, he was able to acknowledge and express, both in session and to his aging father in real life, the deep sadness he felt at having missed out on a healthy and supportive relationship with his father when he was growing up. This, in turn, strengthened his current relationship with his father.

INTERVENTION FOR PROMOTING PRIMARY ADAPTIVE ANGER Unlike problematic anger that needs to be reduced, difficulties with anger also concern its constriction. In short, sometimes the problem is not enough healthy anger. This problem is frequently addressed in the context of resolving issues with perpetrators of abuse and neglect.

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Model of Resolution Using Imaginal Confrontation in Phase 3 The model of resolution using IC was presented in Chapter 6 (see Figure 6.1). We review it here, focusing on later stages in the process and the specific role of adaptive anger in the resolution process. Recall that IC is initially introduced around Session 4 at the end of Phase 1 once a safe therapeutic relationship has been established. It is then used in conjunction with other procedures throughout Phase 2 of therapy (i.e., memory work, working through selfinterruption, self-criticism). The frequency of client participation in IC over the course of therapy will vary depending on individual client processes and treatment needs. As fear and shame are worked through and clients come to tolerate working with trauma material, client difficulties with confronting imagined perpetrators during the IC procedure gradually diminish. Clients become more able to freely express previously inhibited feelings directly to the imagined other. Then, Phase 3 of EFTT begins with the clear and uninhibited expressions of adaptive emotion—in this case, anger at the maltreatment they have suffered. The Degree of Resolution Scale presented in Appendix C can be used to track client progress and set session-by-session process goals. The following example of a client, “Julie,” working through sexual abuse in EFTT, illustrates the three stages in the model. Because the process of resolution is a dynamic and reiterative one, later sessions (e.g., in Phase 3) sometime recapitulate aspects of the previous phases. This excerpt shows such rapid recapitulation of previous work and then advances through steps in the resolution process (see Figure 6.1). CLIENT:

He [her father] is such a disgusting pig! Who treats their own daughter like that?

THERAPIST: I hear how much you hate him, despise him. Tell him over

there [points to chair] what you hate. Make him understand. CLIENT:

Yes, I hate the way you manipulated and corrupted me for your own selfish needs. You perverted everything. I was innocent, and you ruined my childhood; you made sex disgusting. I hope you rot in hell! [sighs, withdraws]

THERAPIST:

What happened just now, Julie—you sigh and kind of collapse?

CLIENT:

I don’t like it. I sound just like him.

THERAPIST:

But you’re not him; you’re nothing like him. You’re justifiably angry, and you want to see him punished for his despicable behavior, for his crimes. Tell him.

CLIENT:

Yes, I do want to see you punished. You deserve to be punished for all the harm you’ve done. You fucked me up royally. My life has been such a mess, but I’m not going to let you ruin my life anymore.

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THERAPIST:

How do you feel saying that?

CLIENT:

It feels right. He was the adult; I was just a little kid. I deserved love and security, not the twisted life he imposed on me.

THERAPIST:

How do you imagine your father over there would react if he knew how you felt—defensive, remorseful, blaming and angry . . .?

CLIENT:

It’s funny. He used to seem so huge and powerful; now, I see just a pathetic old man. I don’t think he’s capable of understanding, but it doesn’t matter anymore. I know the truth.

In this example, therapist interventions supported the client’s anger and entitlement to justice and helped her begin to articulate the effects of the abuse and hold the perpetrator accountable for harm. One of the goals here is for clients to develop a more realistic perspective of the other. An important step toward this is to elicit the client’s understanding of the imagined perpetrator’s response to such a confrontation. Enacting or imagining the other can elicit clients’ empathic resources. This can be particularly important when healing attachment relationships is appropriate and important for the client. For example, a client may come to understand that one or both parents had themselves been victims and would have regretted their behavior with respect to the client. In contrast, when healing the attachment relationship is not appropriate, as in the example of Julie, helping clients imagine (and perhaps even enacting) the other’s response can help them view the other as more human and less powerful. Therapist Operations During IC: Anger Expression in Phase 3 of Therapy The following discussion focuses on specific steps in the model of resolution using the IC intervention that occurs during Phase 3 of EFTT (as outlined in Chapter 6, Figure 6.1). This section describes interventions that facilitate processes in both self and other chairs. Difficulties with resolution, in general, are discussed in Chapter 12 in the context of termination. Before anger can be expressed assertively, it must be differentiated from other emotions. Therapists must decide which, among the different specific emotional constituents a client presents, should be focused on first. At this stage, the client has made considerable progress in working through self-related issues (and the maladaptive emotions of fear and shame), but the trauma is not yet resolved. The decision to now focus on anger, therefore, is based on verbal and nonverbal indicators that anger is the most salient client experience in the moment and needs to be fully experienced and expressed. In the context of memory work or exploring self-critical process in two-chair enactments (Phase 2), the client might have spontaneously expressed anger at a parent for harsh criticism or other forms of abuse. This serves as a marker for switching to express that anger to the imagined parent in IC. Frequently, however, the therapist’s decision

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concerns which adaptive emotion—anger or sadness—to focus on when both emotions are present and expressed at the same time (e.g., anger mixed with tears). This choice is based on previous in-session processes, the individual client’s history, and treatment goals. Repeated client concerns with issues of autonomy, justice, fairness, and respect are indicators for promoting the expression of adaptive anger. Historical information about the client also informs clinical judgment as to whether increasing empowerment or accessing vulnerability will be the most transformative. In general, therapists are attuned to and focus on the affect and meaning that has been least available or least salient (subdominant) in the client’s repertoire. Assuming that anger is the most appropriate emotion to activate, interventions direct the client’s attention to microsignals of anger (e.g., “Lots of feelings here. For now, let’s focus on your anger; stay in touch with that”). If the client shifts back to feelings of fear, guilt, shame, or hurt, the therapist again explicitly redirects the client’s attention to anger. Notice that this oscillation between emotions is the client moving “two steps forward and one step back” in the sequence described in Figure 3.1 (for empirical research on that pattern, see Pascual-Leone, 2009). In the example of Julie, the therapist directly challenged the client’s fear that she was like her father, and this was enough to help her push past her fear. In other instances, a therapist might say, “If you can, let’s not go there. Try to stay away from your hurt feelings for now; stay with your anger,” or “So, her criticism really hurts your feelings, but I also hear you saying it borders on abuse, is out of line—and that it makes you angry.” Assuming the client agrees, the therapist would continue to encourage adaptive anger expression, “Okay, well that’s worth saying too! Tell her how angry you are.” Throughout the process, interventions facilitate client enactment or vivid experiential memories of the imagined other to evoke anger experience and track a client’s shifting perceptions of the other (top of Figure 6.1). As clients become more self-aware and assertive, they also begin to see the other in a different light. The following steps in the IC procedure are characteristic of Phase 3 in therapy (as outlined in Figure 6.1). Promote Expression of Adaptive Anger Toward the Other Guidelines for promoting anger expression during IC are based on the criteria presented earlier in the chapter. Anger is usually first expressed concerning the specific damaging actions or behaviors of the other. Moreover, fully and quickly activating anger and its associated meaning is only possible when the verbal and nonverbal elements of emotional expression are congruent with the presenting situation or context. Although therapists need to avoid being overly directive and concerned about “appropriate” expression, clients can be encouraged to look at the imagined other (or therapist) and to sit up straight, with their feet planted firmly on the floor, and speak firmly from the belly (not the throat). In terms of appropriate levels of arousal, traumatic experiences vary in severity, and the intensity of associated anger will similarly vary, from rage over rape to resentment over invalidation and neglect. Likewise, clients differ

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in expressive style and their history of emotion regulation problems. For clients who tend to be overcontrolled, intensification strategies are useful and appropriate, but they are contraindicated for clients with anger control problems. Ideally, markers of clients’ self-doubt about anger experience can be bypassed, but if not, they need to be further processed by returning to treatment principles from Phase 2. Dealing with revenge fantasies can be a problem both for clients who find them disturbing and avoid them as well as for clients who perseverate and ruminate on them. Clients are encouraged to disclose their revenge fantasies to therapists rather than keep them secret but not to dwell on them. For most clients, these angry fantasies need to be validated as normal reactions to injustice and maltreatment, reframed as unresolved hurt and anger and a desire for justice. Next, therapists need to provide reassurance that working through and resolving one’s trauma will reduce these feelings of tension and the desire to hurt the other. It is important to note that in many instances of childhood abuse, the offender’s behavior was, in fact, criminal, and this also needs to be communicated to clients to help validate the severity of the maltreatment and entitlement to justice. The expression of assertive anger should include the use of “I” language and the specification of wants, needs, and expectations regarding the other, as well as preferred alternative behaviors and articulating the positive effects that these would have had. For example, the client might say, “I was your daughter. You should have believed me, so I didn’t have to spend a lifetime second-guessing myself. This would have made such a difference.” Healthy expression of assertive anger also can involve explicitly setting limits and boundaries, particularly in current relationships. This is a central part of promoting a client’s sense of entitlement to previously unmet needs, which is an essential processing step toward resolution. Again, the EFTT approach to assertiveness “training” involves gradually shaping client behavior through modeling and successive approximations rather than by explicit teaching. In the initial activation stage of IC, the client should not be concerned about “saying it right.” Indeed, such a preoccupation can interfere with clients acknowledging the complexity of their feelings. As clients are chastising or telling the other off (e.g., “You cared more about your bottle and your boyfriends than you did about me, your own daughter!”), the therapist should instead promote ownership of anger experience and symbolization of meaning (e.g., “Yes, so furious about all the damage she caused; tell her more about what makes you so angry”). In this final phase of therapy, clients who do not spontaneously shift to more assertive expressions can be explicitly directed and coached to do so (e.g., “Try saying ‘I hated it when you . . .’”). In any case, it is essential that interventions help clients use clear and specific anger words. Interventions that hint at or imply anger are not specific enough and may tacitly reinforce the inhibition of anger and rumination. Finally, healthy anger expression requires interventions that promote experiencing (see the guidelines in Chapter 5). To that end, it is essential to help the client maintain a balance between outward expression and inward

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attention to the bodily referents of emotion. Verbal expression should emerge from authentic experience (rather than the performativity of scripted, rehearsed, or premeditated expressions). Because of the expressive and interactional nature of IC, a common pitfall of novice therapists is to neglect the experiencing part of this process. Some therapists also get carried away and derailed by the drama of anger expression. An effective EFTT therapist looks for congruence between the client’s internal experience and outward expression and frequently asks the client to “check inside” to ensure that verbal expressions still fit with their internal experience. Interventions that help promote anger exploration focus on the impact of the other’s behavior on the self. This is like formulating a victim impact statement but one that also includes affective arousal in vivo. Sometimes clients ask whether they could formally prepare such a statement for homework or write a letter to the perpetrator (but not send it). These exercises can be effective when they are read aloud by the client in session, and their experience of doing this is explored. Such in-session experiences typically are quite evocative. Promote Expression of Unmet Needs An essential component of meaning exploration is the clear expression of unfulfilled needs and expectations in relation to the other. In the case of anger, these include the need for autonomy or personal control, to defend oneself against threat or harm, and to correct injustices, as well as expectations concerning fair and respectful treatment from others. These needs are motivating and move the process forward. Clients, therefore, are explicitly directed to attend to and tell the other what they wanted or needed (or still want and need) and did not get. Sometimes expressing unmet needs leaves the client feeling vulnerable vis-à-vis the other, particularly when it is a cruel or callous perpetrator. In that situation, the client can be pulled out of the imaginal enactment and encouraged to explore their unmet needs with the therapist. Nonetheless, this includes identifying what was damaging about the other’s actions toward them, how clients feel they should have been treated, and why. For example, the therapist might say to a client, “Instead of your rages and criticism and living in constant fear, tell him what you needed as a child,” or “Tell her how important it would have been if she had actually shown some interest in you.” Track Perceptions of Self and Other Interventions highlight the quality of client expressions toward or regarding the imagined other (e.g., “You sound pretty clear,” or “It’s still not easy to stand up to him, is it?”). These client expressions are also markers for eliciting a response from the other (e.g., the therapist might ask, “How do you imagine he would respond to your demands?”). The quality of this relational process serves as a behavioral index of internalized object relations, which evolve as the client becomes increasingly able to express authentic feelings and needs. It is essential to track these evolving perceptions as indicators of the client’s stage in the resolution process (see the Degree of Resolution Scale in Appendix C). The

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purpose of this tracking is for therapists to offer metacognitive reflections about the client’s process and also as an ongoing assessment of treatment change. Promote an Increased Sense of Entitlement to Unmet Needs The goal here is to help a client not only identify unmet needs but also understand the self in terms of legitimate wants and needs. Ultimately, there is a shift from client self-doubt (e.g., “Maybe I did something to bring it on?”) and the sense that their needs are unrealistic or unattainable to a sense of conviction. Clients come to believe that, like everyone, they deserve to be treated fairly and with respect, to be protected, and to have had a childhood of freedom and innocence, regardless of the opinions, behaviors, or limitations of the other (e.g., “I may not have been the easiest kid, but I was still just a kid! I needed guidance”). Such healthy entitlement helps the client hold the other accountable (e.g., “You were the adult! You should have provided this regardless!”) and motivates efforts to get needs met in current life and relationships. Markers for promoting entitlement are clients’ assertive expressions of need (e.g., “I needed encouragement, not those constant put-downs”) or expectation from others (e.g., “I deserve to be treated with respect, just like anyone else”). Interventions validate these client assertions (e.g., “Yes, of course, all people need and deserve this”) and then direct them to express these clearly to the imagined other. Working with anger in a way that promotes entitlement typically includes the use of verbs such as “will,” “will not,” “insist,” and “refuse.” Once again, it is essential to have clients check whether these expressions fit with their internal experience. If the client is still uncertain about how deserving they are, therapy needs to spend more time exploring and working this through by exploring the raw experience of an unmet need and what it means to be deserving or not. Fully experiencing entitlement to protection, dignity, love, care, and so forth (as opposed to superficial self-affirmations) strengthens self-confidence and self-esteem. Support Clients’ Emerging New View of Self As treatment approaches resolution, interventions associated with anger experience promote and support self-empowerment and gradual separation from the other, letting go of unmet needs and expectations. Clients’ enmeshment with perpetrators is evident in the attention they focus on the other or their dwelling on past injustices and offenses. In situations in which there is current and ongoing interaction with the other, the client may engage in extra­ ordinary efforts to please these others, have difficulty asserting themselves for fear of offending them, or try to force the other to apologize, admit they were wrong, or change. Interventions should first heighten client awareness of enmeshment, victimization, and powerlessness (e.g., “It’s like you can never be happy; unless she changes, you are doomed!”) or exaggerate a client’s maladaptive efforts to force the other to change (e.g., “Try saying, ‘I will force you to apologize; I demand that you apologize’,” or “Try saying, ‘I cannot live until you respect me’”). Alternatively, the therapist might role-play the imagined other’s response

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to promote a client’s letting go of unmet needs (e.g., “And so, what if the response is like, ‘It doesn’t matter what you do; you can turn yourself into a pretzel, but I will never give you what you want’?”). These are obviously paradoxical interventions that can help a client react to the feared outcome in concrete ways or perhaps abandon the fruitless hope the other will change. Through this kind of enactment or imagining, clients eventually come to see that they cannot force the other to change or acknowledge wrongdoing. Letting go emerges partly from fully experiencing a sense of deserving or entitlement to unmet needs in an earlier step. Here, clients no longer feel like defenseless children and no longer seek the other’s approval to feel good about themselves. For instance, one client who was taken from his family, stripped of his language and culture, and sexually and physically abused in an “Indian residential school” for Indigenous children naturally wanted official recognition and an apology from the church, government, and individual perpetrators. Partly through the expression of his anger and then validation from the therapist, this client began to feel that an apology was owed and deserved, even though he may never get one. Many clients also become more aware of how important issues of justice and respect are to them and resolve to promote these values in their current life. For example, another client who had been abused as a child decided to become a lawyer, another volunteered to work for Victim Services, and yet another vowed to become a better parent. Support the Emerging New View of the Other and Relationship In the early phase of therapy and IC, the other is perceived narrowly and negatively—one client viewed her physically abusive and rejecting mother as “the devil.” However, at this step, people can see the other more realistically, partly because their own feelings and needs have been expressed and validated. Thus, as the client gets closer to resolution, the goal of enacting the imagined other shifts. Rather than using the imagined other strictly as a stimulus for evoking feelings in the client, the emphasis now is more on promoting experiencing while the client is in the “other” chair. This helps flesh out the imagined other’s perspectives, feelings, and motives. Ultimately, this process draws on clients’ capacity for empathy. Therapists can ask clients, for example, how they imagine the other would feel “on the inside” or “in their heart,” even if they cannot imagine the other expressing remorse or directly apologizing. Clients develop an increasingly rich understanding of the other and may develop an appreciation of the limitations and frailties of those who have mistreated them. Whether or not clients feel compassion toward the other, they come to see their perpetrators as more human, life-sized, and less powerful. Importantly, compassion and forgiveness of the other come through acknowledging and expressing legitimate anger and its associated meaning, not through denying anger. In the ideal situation, the client might imagine that the other regrets and takes responsibility for the harm done (or feels regret but could never admit it). In these cases, resolution is more likely to be accompanied by forgiveness. As we have discussed, this is particularly true when the other is or was a neglectful primary attachment figure with whom the client wishes

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to restore relations. In other instances, clients begin to accept that the other will never respond to their feelings and needs—the other does not have what is required. Some clients come to perceive the other as mentally ill or pathetic. In any case, forgiveness, as we define it, is not excusing or condoning the other’s behavior, instead clearly and appropriately holding the other accountable for harm. End Contact With the Imagined Other and Process the Meaning of the IC Experience These last two steps take place at the end of each IC and are particularly important aspects of the final IC and therapy termination. However, it also is essential to identify and accept the degree of resolution achieved in each session, whatever it is. If issues with the other remain unfinished, clients should be encouraged to say so and state their intention to return to the issue in the next session. Resolution is a cyclical and reiterative process, so therapists can use the Degree of Resolution Scale (Appendix C) to evaluate a client’s progress and set process goals for the next session. In this chapter, we reviewed the model of interpersonal trauma resolution that is the basis for EFTT. This model specifies experience and expression of adaptive emotion as the catalyst for change. We also reviewed the model with a particular focus on the role of anger in resolution. The next chapter focuses on the role of sadness in resolution.

11 Resolution of Interpersonal Trauma Through Sadness and Grief

F

ull experience and expression of sadness frequently follow the process of working through anger and resentment toward the other once the client has developed a stronger sense of self. The focus on activating adaptive anger in emotion-focused therapy for trauma (EFTT) can be controversial largely because of a failure to distinguish between adaptive anger and destructive anger (frequently associated with posttraumatic stress disorder [PTSD]) that needs to be reduced (see Fernandez, 2016). However, researchers and practitioners alike view the resolution of trauma achieved through sadness and grief as healing and curative. Indeed, for many clinicians, trauma work is synonymous with grieving. However, despite a large literature on the complex process of grief, little has been written on working with the discrete emotion of sadness. Furthermore, although most approaches to therapy for complex trauma recognize the importance of grieving traumatic losses, only EFTT explicitly focuses on accessing adaptive sadness as a specific and essential step of that larger process. In this chapter, we briefly review the literature on traumatic grief across theoretical perspectives, highlighting EFTT’s distinct emphasis on sadness as a discrete component in that process. We also describe different types of sadness observed in trauma therapy and principles of intervention with each of these types. The intervention sections provide guidelines for working with sadness and grief as a route to resolving interpersonal trauma during imaginal confrontation (IC), resolving self-related losses, and reducing depression.

https://doi.org/10.1037/0000336-012 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  257

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TRAUMATIC GRIEF ACROSS THEORETICAL PERSPECTIVES Fully experiencing the depths of one’s sorrow and accepting losses can be the most difficult aspect of trauma recovery. Experiences include the loss of loved ones and cherished aspects of the self. Sadness related to trauma also frequently includes intense feelings of loneliness, isolation, and an inability to communicate one’s feelings. Profound losses are especially associated with childhood maltreatment when children are deprived of innocence, self-respect, security, and love. In cases of neglect, the developing child is deprived not only of attention, recognition, contact, and comfort from attachment figures but also of basic stimulation and feedback from the environment. Neglect leads to profound loneliness, longing for attention and recognition, and a sense of the self as negligible or unworthy of attention. The absence of information and feedback from attachment figures results in uncertainty about the self—one’s feelings and values, for example—and anxiety about the expectations of others. Grieving losses is a complex process that can take place over many years and involve many emotional processes, including denial, anxiety, anger, despair, depression, and sadness. People seek therapy for traumatic separation and loss because they “can’t get over it.” They have not been able to complete the grieving process and move on with their lives. Several factors can interfere with normal grieving. People can be preoccupied with coping with the effects of the trauma or have limited support for coping, such that grieving is suspended and left incomplete for years. Grieving profound losses is possible only after traumatic fear becomes less intense and some sense of safety has been restored. When that time comes, a supportive therapeutic relationship, along with interventions that affirm and validate client losses, will provide the support that likely has been missing in the environment. In other instances, the therapeutic process is more complex and involves actively changing certain maladaptive processes that have interfered with grieving and resolution. For example, other emotions (anger, fear, guilt, shame) or injunctions against grieving (e.g., “I shouldn’t be so upset about this; others have it so much worse”) can either overshadow or interrupt sadness. Changing these maladaptive processes is typically the focus of the second phase of EFTT, presented in Chapters 7, 8, and 9. Resolution of past interpersonal trauma can also be complicated by ongoing interactions with the offender to whom the client is still attached—emotionally, financially, functionally, or socially. In these instances, healthy expression of sadness as part of grieving traumatic loss may need to be distinguished from a maladaptive sense of powerlessness and depression in current situations. The client Monica, whose mother committed suicide, was a case of a client with complicated grief because she had not been able to get over the death of her mother. Her sorrow was more like anguish, and her tears were mixed with anger at betrayal and the chaos of her life. Being traumatized and saddled with the burden of memories, recurring trauma symptoms, and family

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responsibilities deprived her of a happy childhood and a normal family life. Monica blamed her mother for the premature death of her father and her own and her siblings’ subsequent struggles and suffering. She also felt shame, tainted by the “unspeakable” atrocity. These feelings had never been validated or fully expressed and interfered with her ability to come to terms with her mother’s suicide. Over the years, the message she received from family and society was, “Let it go. Don’t think about it; what’s done is done. Your mom was sick; you should forgive and forget.” These well-intended messages not only prevented Monica from being able to fully grieve but also prevented her from making sense of her mother’s death. For example, she lamented, “I don’t understand it. I don’t accept those explanations; they just sound like excuses, and what she did was inexcusable.” Later, in an imagined confrontation with her mother, she eventually said, “I need to know why you did what you did.” Over the years, she had “cried buckets,” but without clearly articulated meaning, this global distress had not been therapeutic weeping. Before she could fully experience the depths of her sorrow, Monica first needed to achieve some support in tolerating the pain and distress of the trauma, resolve her feelings of shame, and fully express her anger and resentment. Coming to terms with traumatic loss involves the process of allowing emotional pain (Greenberg & Bolger, 2001; Greenberg & Paivio, 1997), which was introduced in Chapter 8. Clients must make a conscious decision to allow the pain of separation or loss and fully experience and express the associated sadness, sometimes for the first time. This process accesses the specific information and meaning associated with sadness and helps clients identify what was missed or missed out on—the needs that were not or are not being met. Needs that are brought clearly into awareness are motivational and act as behavioral goals. Although the client will never get back the lost person, part of the self, or missed opportunities, they can still move on to build a new life, have personal needs met, and find new meaning. Most contemporary models of mourning (e.g., Neimeyer, 2016) understand loss in terms of disruptions in meaning. For instance, a woman who lost her husband of 20 years in a plane crash lamented, “I can’t seem to wrap my head around it. I am no longer Mrs. B. . . . Like, who am I?” Current cognitive behavior therapy approaches for complicated grief (e.g., Boelen et al., 2006; Currier et  al., 2015) use standard cognitive restructuring interventions to reduce depressive withdrawal and avoidance that interfere with recovery. These approaches may also use techniques that are like IC used in EFTT to foster “communication” with the deceased and thereby promote acceptance of the loss. Current narrative constructivist approaches (e.g., Neimeyer, 2016) focus on disruptions in personal narratives (coherent meaning) that occur through traumatic loss. In these approaches, therapy is a process of constructing a new personal narrative that includes strength, survival, and growth. EFTT bears considerable affinity with these narrative-constructivist approaches, except that we focus more explicitly on affect, particularly the central role of sadness, in the resolution of loss. Through the full experience and expression

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of sadness during Phase 3 of EFTT, clients develop a clearer view of self and can fully acknowledge and understand how experiences of loss functioned in their lives. Moreover, this process unfolds in the context of a therapeutic relationship that provides warmth, intimacy, and connection. This can be a new learning experience that increases the likelihood of clients seeking support in other relationships. Thus, the full experience of sadness at loss is what, specifically, seems to precipitate posttraumatic growth (Tedeschi et al., 2018). It is only in facing the emptiness of a loss and in “saying goodbye” that one can build something new. Although painful, the full expression of adaptive sadness is a catalyst for resolving attachment injuries related to deprivation, separation, and loss. It is important to note that this is not a linear process—sadness can be fleeting, and the client may shift back into anger or fear. Clients need to anticipate and learn to cope with the recurrence of pain and sadness—for example, at the anniversaries of a loss. Resolution and growth do not preclude anniversary reactions or other periods of distress; rather, these periods are associated with an increased capacity to cope with the distress and move on. Clients can learn to be kind to themselves (self-compassion, described in Chapter 9) and seek support from others but may need to accept that the pain of profound loss may never completely go away. They can learn to honor reoccurrences of pain as indications of the depth and extent of their loss—that the persons and lost aspects of the self are worth the pain. For example, a client whose two grown daughters died of alcohol-related illnesses, with time, learned not to fear holidays like Christmas when memories flooded her awareness and old wounds were revisited. Instead, she learned to accept that, at these times, she needed to honor her grief by withdrawing and allowing herself to grieve again for the loss of her daughters. Thus, fully experiencing sadness and awareness of the associated needs can help clients cope with anniversary reactions and learn what to do to better care for themselves.

PROCESS DIAGNOSIS: DISTINGUISHING DIFFERENT TYPES OF SADNESS The following subsections describe sadness as a basic emotion and distinguish among different types of sadness observed in trauma therapy. Characteristics of Sadness as a Basic Emotion Whereas anger emerges from violation, and its expression promotes separation and distance from others, sadness promotes closeness and connection to self and others. The latter occurs partly because sharing the vulnerability and distress of sadness elicits comfort and support. Sadness, unlike anger, is inwardly directed and involves loss of energy, feelings of heaviness and collapse, downcast eyes, and a weak, quiet vocal quality. People sometimes feel

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as if they want to lie down or curl up into a ball. This has implications for therapeutic interventions that are intended to promote sadness experience and expression. There are two action tendencies associated with sadness. One is to withdraw to heal and recuperate from the loss; this frequently is observed in mourning the loss of a loved one. The other is to seek contact and comfort from supportive others to reduce distress (i.e., “a shoulder to cry on”). Community and family grieving and rituals (e.g., funerals) strengthen bonds among group members. So, these and other forms of shared sadness can strengthen interpersonal connection. Emotional pain and distress are closely related to experiences of sadness. As discussed in Chapter 8, emotional pain is an experience of feeling broken or shattered and involves complex and idiosyncratic meaning about a psychological injury. Emotional pain is associated with primary sadness only when the pain concerns deprivation, separation, or loss. In contrast, crying in distress is a general signal of suffering and a cry for help, and global distress, like emotional pain, is associated with a wide range of emotions such as fear, shame, anger, and sadness. At the beginning of therapy, clients are frequently highly distressed and might cry easily about the things that are bothering them. However, they usually are not expressing primary sadness at an articulated loss. Appropriate interventions, first, need to clarify the sources of distress and differentiate them into specific emotions (see Figure 3.1 in Chapter 3). Subsequent interventions differ depending on the emotion. Adaptive Sadness The following subsections describe primary adaptive sadness and specify criteria for its healthy expression in therapy. Primary Adaptive Sadness Adaptive sadness can emerge as a fluid moment embedded in the more complex process of therapy or can be deeply felt and involve intense sobbing. It is not uncommon for this type of sadness to be suppressed or not expressed in a manner that is distinct from other emotions, which can make it difficult to address. Markers of sadness suppression include intellectualizing, minimizing pain, covering with anger, and experiencing an explicitly stated unwillingness to let oneself cry or “go into the pain,” along with concerns about being overwhelmed. Physiological markers of suppression include tensing muscles, holding one’s breath, and holding back tears. Knowledge about the situation and the individual client helps a therapist distinguish adaptive from maladaptive sadness such as depression. Sadness involves accepting loss and the realistic hopelessness of undoing the loss, which is distinct from the lingering hopelessness, resignation, and defeat of depression. Knowledge of the situation also provides information about other emotions that are likely to be present, along with sadness, as part of an undifferentiated emotional experience. For example, in situations of betrayal, sadness is typically

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mixed with anger; in situations of trauma, sadness can be mixed with fear and anger; in situations of violation and abuse, sadness is usually mixed with anger, fear, and shame. All these emotions can be primary, and all need to be experienced and expressed separately and completely. Interventions do this by helping clients articulate and experience each emotion, one at a time. Interventions for sadness focus on the aspects of deprivation and loss in an experience (e.g., the therapist might say, “I understand how angry you are at her abandonment, and, at the same time, it must be so difficult to be dealing with it all alone—so lonely”). Criteria for Healthy Sadness Expression Criteria for adaptive sadness experience and expression in therapy resemble those described for anger. Healthy sadness needs to be differentiated from other emotions, such as tears of loss, rather than powerlessness or fear. Arousal levels for sadness expression need to be suitable to the situation, such as quiet weeping about missed opportunities or deep sobbing over the death of a loved one. Sadness also needs to be expressed assertively with an ownership of the experience (e.g., use of “I” language, inward focus, not blaming) and should include exploration of the meaning once arousal levels subside (e.g., after one has had a “good cry”). Unlike anger, however, adaptive sadness can be directed toward the self, as in acknowledgment of and compassion for one’s suffering. Problematic Sadness The following sections distinguish three main types of problematic sadness observed in trauma therapy, beginning with primary maladaptive sadness. Primary Maladaptive Sadness It takes time to determine whether expressions of primary sadness associated with traumatic loss are, in fact, maladaptive. The situations that trigger feelings of sadness may be appropriate, but if, after repeated expression, nothing shifts or there is a dysfunctional quality of fear, fragmentation, inability to cope with loss, or helplessness, it may suggest problems with underregulation or a core sense of vulnerability or low self-esteem. These features have undertones of either primary maladaptive shame or fear, which can be the more foundational elements of sadness that is chronic, enduring, and painfully familiar. However, even though fear and shame may better explain the root of primary maladaptive sadness, case formulation and clinical work should also reflect how clients experience themselves. This is particularly true when clients (unfortunately) hold onto their sadness or loneliness as a part of their identity. Fear, fragmentation, and regulation problems may be associated with the severity and magnitude of a loss. This is the case, for example, with some refugee trauma survivors who have witnessed the destruction of their community and the mutilation and/or murder of loved ones. In these instances,

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intervention focuses on containment and regulation of distress. Pathological or complicated grief is another example of primary maladaptive sadness in which the person is unable to cope and move on. Here, accessing and working through unexpressed anger and possibly guilt (e.g., over failure to protect a loved one) may be important parts of intervention. Another dramatic instance of primary maladaptive sadness is the paradoxical sadness that may be in response to expressions of kindness and tenderness from others. These expressions from others are like evocative reminders of a deeply felt sense of deprivation, unmet dependency needs, and an ocean of longing to have these needs met. In one case, for example, a client’s eyes welled up in tears at expressions of compassion from the therapist. Intervention in these cases involves accessing and exploring the core maladaptive sense of self as alone and unloved. The process of change occurs partly through a corrective emotional experience with an empathically responsive therapist who reduces client isolation and distress, as well as by developing the capacity for self-soothing and seeking comfort from others. Ironically, the person often needs to feel less deprived before they can tolerate and receive kindness. Secondary Sadness Tears can accompany many experiences besides sadness, and clinicians should be mindful not to jump to conclusions at the first sign of crying. For example, clients who have been violated and abused can repeatedly collapse into hurt, helplessness, victimization, or resignation when anger is the more primary emotion. Such secondary reactions are recognized by verbal or nonverbal cues and, as in other secondary emotions, by their temporal sequence. In this case, tears are preceded by cognitive–affective processes, such as expressions of anger at a loved one and the anticipation of rejection because of one’s anger, which then results in fear, distress, and sad feelings. Interventions explore the cognitive–affective sequences leading to this secondary emotion and promote understanding of the deeper meaning to arrive at the core experience. At other times, the most salient feature of secondary sadness is how undifferentiated and global it is. A client might feel overwhelmed and confused (e.g., “I just feel sad and break down in tears, and I don’t really know what it’s about”). The lack of specificity in meaning is a hallmark of global distress (top of Figure 3.1.) and is a sign that clients need help to differentiate and find the right words to symbolize the more specific emotional experience. When it becomes a chronic state, global distress is also a common part of depressive symptomatology. Depression Depression is a complex pathological state characterized by a sad mood that can have unacknowledged primary emotion at its core—the emotions may be either primary maladaptive or adaptive, and often there is some of both. Depression is most prominently associated with anhedonia or the inability to experience pleasure and ruminative negative thoughts, typically about oneself.

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As noted in earlier chapters, emotion-focused therapy views depression as stemming from the activation of a maladaptive emotion scheme or structure characterized by a weak or bad sense of self (Greenberg & Watson, 2006; Salgado et al., 2019). This consists of a network of meaning that includes negative thoughts about the self (e.g., “I’m such a freak—who could love me?”) and feelings of worthlessness, hopelessness, powerlessness, and defeat. The depressive emotion scheme also includes somatic experiences, such as heaviness and low energy, and behaviors such as social withdrawal. A depressogenic sense of self is a common development from complex trauma when the individual suffered repeated experiences of profound powerlessness and helplessness in the face of danger and betrayal. People typically try to control their depressed mood by suppressing or distracting themselves from negative thoughts. However, there is abundant evidence supporting the view that distraction and suppression can be counterproductive—they can maintain or exacerbate the mood state (see Chapter 8, on avoidance). Mindfulness-based cognitive therapy for depression is based on this view (Segal et al., 2013). In that approach, clients learn to nonjudgmentally observe and accept the inevitable flow of thoughts and feelings rather than ruminating or attempting to suppress them. EFTT intervention similarly involves helping clients allow bad feelings of hopelessness and defeat. Unlike mindfulness, however, allowing bad feelings is for the purpose of subsequently exploring and constructing new meaning. Client change is accomplished by finally arriving at some healthy experience, such as primary adaptive sadness, which can help generate responses of compassionate selfsoothing. The synergy of these experiences facilitates grieving, accepting the loss, and making interpersonal connections (see the lower part of Figure 3.1.).

CHANGE PROCESSES AND GOALS The intensity of emotional pain and the duration of the grieving process vary depending on the nature of the loss and the culture, personality, and other demands faced by the griever. Traumatic grief takes longer to address because resolution first deals with the underlying trauma. Similarly, in EFTT, sadness associated with complex trauma often can only be adequately dealt with after fear and shame are addressed, and the client’s sense of self has been strengthened through the experience of anger. Grieving is also harder to bear and takes longer if traumatic loss involves horrible images and memories (e.g., the suicide of a mother through gunshot, experiences of refugees of war). The presence of PTSD also indicates recurring trauma memories and grief reactions. Trauma survivors are more reactive to recurring grief and need to accept that they have been wounded by the trauma and that wounds take time to heal. We want to emphasize here that allowing the pain of loss as part of the grieving process is not a simple cathartic event but rather involves complex feelings and processes that usually take place over considerable time. The goal

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of therapy in the early stages of resolving traumatic loss was to help clients tolerate and stay with these complex processes. Sadness expression occurs in this larger context and is usually fully experienced and expressed during Phase 3, the final phase of therapy. Steps in the process of allowing emotional pain and resolving interpersonal trauma using IC or evocative exploration (EE) were presented in earlier chapters. The following discussion summarizes and combines critical processes and goals with a focus on the specific role of sadness in grieving and resolution. Allow the Pain, Accept the Loss, and Express Sorrow The first goal is to help the client let go of the struggle to avoid pain or relinquish efforts to hold onto the lost object. Once a loss is accepted as irrevocable, at least for the moment (e.g., a client says, “I will never get back that innocence; it’s gone forever”), a new and more realistic view of the self can emerge. Thus, the goal of therapy in this phase is to facilitate and support a process of deep grieving that includes the expression of sadness. This process could take place in interaction with the therapist, an imagined supportive other, or an imagined part of the self. As the client comes to accept the damage that has occurred to the self, it opens the way also to develop an increased sense of agency—built on a new horizon of realistic possibilities. Promote Awareness of Specific Losses and Associated Needs An important goal in working with sadness is to help the client specify what is and/or was missed, missed out on, wished, or longed for, in terms of both interpersonal and personal losses (e.g., hopes, dreams, cherished beliefs, assumptions, identity). Awareness of specific losses provides both information and motivation for realistically replacing what is still missed and getting one’s needs met. Promote Self-Exploration The goal is to promote experiencing—exploring feelings and meanings related to the loss. In narrative terms, this means shifting from chaos to coherence (Neimeyer & Sands, 2015; Paivio & Angus, 2017), making new meaning, and coming to terms with the loss. Change processes of this kind begin when clients start to ask questions about themselves and their loss (e.g., “Why has God taken this away? What is my purpose?” or “All those years of degradation—what makes me think anyone would respect me?”), and the client engages in a deliberate effort to formulate answers and construct a more coherent understanding of self and traumatic events. An important issue concerning meaning construction is illustrated in the case of Monica. A major focus of her therapy was Monica trying to make sense of her mother’s suicide. Of course, it is impossible to know why the mother

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did what she did, and the challenge for therapists in situations like these is not to push for any specific content or ending to the story. Also, for clients like Monica, who cannot obtain more corroborating information about events or significant others, a new and more coherent understanding is one that makes sense to the clients themselves and that fits with their existing experiential memories and stories. This understanding only emerges from the process of exploring and clarifying aspects of experience and the story (see Chapter 7 on reexperiencing) as they emerge in session.

INTERVENTION PRINCIPLES FOR PROMOTING ADAPTIVE SADNESS This section presents intervention principles that are important in promoting the experience and expression of healthy sadness about separation and loss. These principles stem from the specific nature of the sadness experience described earlier. Ensure an Appropriate Time and Therapeutic Environment Conducive to Sadness First, the therapist and client may need to collaborate on an appropriate time to focus on grieving. Grief may have to be postponed to a time when clients are not overwhelmed by external demands and responding to problems imposed by the trauma. When grief is a focus of therapy sessions, therapists need to ensure that clients have a time and place to be with their feelings outside of therapy or can reasonably manage their feelings between sessions. Establishing an appropriate therapeutic environment for working with sadness and loss begins with the provision of safety. Clients must feel safe enough to allow themselves to collapse and be vulnerable with their therapist. Moreover, in IC work, clients must feel that the imagined other—typically someone they want to restore a connection with—potentially will respond with compassion and comfort. They will not allow themselves to be vulnerable in the face of an imagined other who continues to be viewed as cruel or abusive. Using or switching to the EE intervention in these circumstances effectively avoids this potential obstacle by having clients disclose without an imagined perpetrator. Vulnerability and expressed sadness increase the likelihood of intimacy because they invite the possibility of supportive reactions from imagined others. For example, the client Monica could fully express her sorrow toward her imagined mother only after she imagined that her mother would hear her anger and take full responsibility for the harm she had caused. However, the therapist should not assume that because the client could not or would not express sadness toward an imagined other in the early phase of therapy, the situation will remain unaltered. As noted in earlier chapters, appropriate intervention requires ongoing tracking and assessment of a client’s evolving perceptions and goals in terms of relations with the other.

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Provide Validation, Encouragement, and Support Above all, when working with sadness, therapists need to feel and communicate deep compassion for their clients’ suffering and pain. They need to validate the importance of the loss and how hard it is to approach these feelings (e.g., “It’s terrible for a child to feel so alone and unloved; so hard to feel that again,” “How many tears you must have cried for your beautiful daughters”). These interventions normalize client grief and help them allow these painful feelings because they are no longer suffering alone. Therapist compassion and nurturing are internalized by clients and contribute to their capacity for compassion toward the self and self-soothing. Interventions that provide support include the therapist’s soothing presence, vocal quality, and giving clients the “space” they need to focus inward and momentarily withdraw from personal contact to heal. In terms of eliciting self-soothing responses that do not spontaneously emerge (see Chapter 9), therapists can ask their clients how they would respond to a friend or loved one if those people were grieving such an important loss. Strengthen Clients’ Sense of Self The conscious choice to eventually allow the pain of loss comes about because clients feel safer in the environment but also because they feel less fragile. One of the features of unresolved trauma is weeping in distress about feeling victimized and powerless (i.e., fear and shame) rather than about accepting one’s loss (i.e., grief). We have noted throughout the book how accessing healthy anger at violation can help reduce a client’s sense of victimization and powerlessness. Anger as a basic emotion is associated with strength and vitality, finding one’s “backbone,” and, therefore, contributes to strengthening the self while dealing with loss. For example, the client John, whose mother died of a drug overdose, resisted facing the pain of her death. After several sessions that focused on his anger about his subsequent abuse in an orphanage and brief expressions of sadness, John was able to focus more fully on grieving the loss of his mother and the many associated losses and suffering he had endured. Many basic emotion-focused therapy intervention principles, described in earlier chapters, also are particularly important in promoting the sadness experience and expression. First, it is essential to create a peaceful and quiet environment so the client can withdraw and focus inward. Second, presentcenteredness and responding to the clients’ moment-by-moment process are crucial because the emergence of primary sadness can be subtle and fleeting (e.g., eyes momentarily welling up in tears, downcast eyes, a wistful tone of voice). Therapists must be flexible in modulating their responses (e.g., vocal quality) to match the emerging experience of the client. Sadness can also quickly shift to other emotions such as fear or anger (and vice versa) or to self-protective withdrawal. Therapists also need to recognize the difference between natural shifts to another primary emotion, such as anger, and shifts to secondary emotions that indicate avoiding vulnerability or pain. These distinctions have obvious implications for appropriate intervention.

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Promoting sadness at loss also can involve increasing arousal to the point at which suppressed sadness can no longer be ignored. Interventions include memory evocation (e.g., references to the client as a child), evocative empathic responses that are personal and poignant and that use imagery and metaphor (e.g., “a broken heart,” “a big gaping hole inside”), references to bodily experience (e.g., feelings of heaviness, aching, emptiness), and use of enactments. Imagining the self as a child and fully experiencing the pain of being unloved, for example, can elicit deep compassion or empathy for the self and nurturing, soothing responses. The final intervention principle is helping clients to symbolize the meaning of sadness and loss. Without the consistent effort of the client and the carefully refined reflections of the therapist, grief can quickly unravel into a more global sense of distress. This is the essence of “therapeutic weeping,” as opposed to clients who have “cried buckets” with no glimpse of resolution. The intervention principles involved in promoting client experiencing presented in Chapter 5 are also relevant here. Targets of exploration include somatic experiences; causes of the pain; specific losses and associated wants, needs, and desires; the effects of the loss on the self and self-identity; and perceptions of the self and others. Therapists encourage clients, for example, to verbally symbolize bodily experiences (e.g., “Put words to your tears” or “that ache inside” or “what weighs you down”). Symbolizing the pain of loss helps create distance from it and make it comprehensible. Once again, identifying what is and/or was missed or missed out on is central to the meaning of sadness and the source of one’s emptiness and pain. When clients feel sad, they need to know what they feel sad about (e.g., the therapist might ask, “What is that emptiness? What is missing?” or “What did you long for, or crave, more than anything?”).

INTERVENTIONS FOR PROMOTING SADNESS AND GRIEVING LOSSES Specific change processes ensue when sadness concerning an attachment figure is fully expressed during IC. This specifically promotes empathy for and connection with the other. In the sections that follow, we identify steps in the process that parallel those related to anger (see Chapter 10)—anger and sadness often act as two sides of the same coin. Promoting Primary Sadness Over Attachment Injuries In response to client markers of unresolved deprivation, separation, or loss concerning an attachment figure (e.g., “It tears me apart every time I think of her”), the therapist can initiate a focus on experiences of sadness (e.g., “Let’s stay with this pain and sadness for a moment”). Alternatively, the therapist and client may collaboratively decide that focusing on sadness and loss will be most productive for the client. In cases in which unproductive anger is a

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client’s dominant experience, for example, the therapist can raise this issue for discussion and suggest the goal of expanding the client’s emotion repertoire (e.g., “It seems as if you feel sad about this as well, never getting the attention you needed. I think it would be useful to explore that other side of the coin. I guess it would be hard to go there, but still . . .”). Once sadness has been activated, the client can then be directed to express this to the imagined other in IC. Therapist Operations During Steps in the IC Task General steps in the IC task are outlined in Chapter 6, Figure 6.1, and steps specifically related to anger were outlined in the preceding chapter. When the process relates to sadness, promoting psychological contact with the imagined other again requires that the other is seen as capable of responding with sympathy and support. If this is not the case, it is most beneficial for the client to express sadness to the therapist (e.g., in EE) or another part of the self (e.g., in a two-chair dialogue). Client weeping in the early phase of therapy is typically accompanied by hurt, blame, and complaint about the other. At the beginning of therapy with Monica, for example, her tears were mixed with anger, and the process oscillated between anger and sadness. Despite an early focus on helping her work through her anger, the therapist was continuously attuned to the presence of sadness as Monica described new events concerning her mother (e.g., “It’s so sad seeing those old pictures of her—so young and beautiful”) and empathically responded to her laments (“Yes, really tragic you missed out on so much”). Later in therapy, the therapist explicitly encouraged Monica to stay with these painful feelings of sadness (“Tell her how much you have missed her, all the things you have missed over the years”). Specifying what she had missed out on elicited the softening typical of sorrow—that is, vulnerability, turning inward, and a longing for contact and comfort (“I missed you seeing me graduate, getting married, even just going shopping . . . I see other women with their mothers, and it always hurts so much”). This marked the shift to steps in the resolution process typical of Phase 3 of therapy. These steps, as they apply to sadness, are outlined next, beginning with the middle part of Figure 6.1. Promote Healthy Sadness Expression To promote the full experience and expression of sadness, interventions may first need to address problems with emotion regulation. This includes providing empathic affirmation of vulnerability, reassurance, soothing, and comfort to reduce distress. In other cases, this would include the use of evocative language to increase arousal and activate core emotion structures. As noted, helping the client reexperience themself as a child can be particularly evocative. It is critical that a therapist’s nonverbal behavior (quiet, soothing voice; leaning forward) is conducive to the sadness experience and helps the client turn inward.

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Identify Unmet Needs As in the example of Monica, unmet attachment needs emerge from identifying specific losses in relation to the other. Clients can find it difficult to acknowledge the depths of their neediness and longing because of the emotional pain, unresolved anger, or difficulties admitting weakness or vulnerability. Effective intervention for client difficulties with vulnerability depends on whether the problem concerns avoiding the experience of vulnerability per se or the interpersonal disclosure of vulnerability—to the imagined other or the therapist. When clients resist expressing neediness to the imagined other, interventions need to distinguish the present from the past (i.e., what was needed as a child) and direct clients to speak about their past needs, which are frequently more evocative than their adult situations. For example, a client entered therapy saying she had been “sad for years.” She perceived her mother as “mean,” constantly criticizing, never telling the client she loved her or praising her. Although the client still maintained a relationship with her mother, she held her mother in contempt. In session, she was unable to acknowledge how much she wanted affection from her mother, such as a hug (“Not now; it’s too late. It makes me sick even thinking of it”). This refusal to entertain her need for affection was conflicted because of both her anger and the intensity of her longing (“It’s yucky, embarrassing”). The therapist acknowledged the client’s resistance (e.g., “I hear how much you distrust her and would never expose your feelings to her right now”) but then responded to her sadness. These responses validated the extent of the client’s deprivation and pain and helped her acknowledge her hunger and longing for her mother’s love. The therapist asked the client, “Feeling sad for years—what’s that about? A big ache inside—can you put words to that ache? As a little girl, what did you long for more than anything? What was the worst part?” The client initially expressed longing to the therapist, and later interventions returned to IC with the mother. Track Perceptions of Self and Other Tracking client perceptions of the self and other throughout the dialogue process is part of exploring meaning by promoting client experiencing. Clients can also be directed to tell the imagined other or tell the therapist, in the case of EE, about themselves (e.g., “Tell him what he [the father] missed out on, what kind of a person you are”). Perceptions of the other are elicited by enacting or imagining the other’s response to the client’s expressed sorrow, disappointment, and longing. Aside from the other’s perceived capacity for responsiveness, core issues regarding sadness expression concern whether the client wants to maintain or regain connection with the real or internalized attachment figure. This is also related to the importance a client places on forgiving an offending other. These issues will shape the process of interaction with the imagined other and determine the type of resolution that is possible.

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Increase Sense of Entitlement to Needs It is important to increase clients’ conviction that their unmet attachment needs were and are essential to their development and happiness and that they are deserved, rather than seeing them as excessive, self-indulgent, or trivial. This is accomplished by directing clients’ attention to and validating these needs in relation to the other (e.g., “Yes, of course, all children need attention and recognition, need to know that they are important”). Needs that are fully acknowledged and owned become the motivational aspects of meaning. Clients who can both experience and admit the extent of their loneliness and their need for connection and intimacy are more likely to seek out ways to get these needs met in their everyday life. Support Emerging New Perceptions of Self A clearer and more realistic view of the self emerges, in part, from allowing emotional pain, letting go of needs and expectations regarding the other person, and accepting losses. Here, we need to distinguish resolution and acceptance of loss from the untenable pseudo-resolution of resignation and powerlessness. Interventions in EFTT facilitate a gradual process of acceptance and letting go. Therapists need to avoid forcing or supporting premature or pseudo-acceptance. Difficulties in this area are discussed in more detail in the following chapter on termination. Facilitating genuine acceptance requires helping the client sink into the sense of hopelessness at the irrevocable nature of the loss (e.g., “Stay with that—knowing you will never have the kind of family you wanted, it’s so hard to let that go”). The therapist might direct clients to attend to their bodily experience—for example, “Go inside, speak from that heaviness. What does it say?” Along with inter­ personal losses, clients also need to accept the limitations imposed on them by the trauma (e.g., difficulties they currently have with intimacy and trust). A particularly painful and difficult situation occurs when clients must accept and grieve the reality that they were not wanted or loved by an attachment figure. One of the clients described in an earlier chapter alternated between current issues of nonassertiveness with his employer and a focus on past issues with an alcoholic father who had been emotionally and physically abusive. In a pivotal session, the client recalled an incident in which his father showed up late and drunk for the client’s birthday, then “proceeded to break my heart by breaking all my presents.” Therapy with this client was a gradual process of approaching and accepting the painful reality that his father had never loved him and that all his efforts to secure that love were futile. Interventions to help the client with his sadness included affirmation of vulnerability, provision of comfort and support, and validation of his experience and perceptions. The therapist said, “This is so incredibly hard to accept that you were not loved by the one person you needed it from the most. You missed out on so much—you both did. What a shame.” Therapy repeatedly returned to this theme until the client was able to fully acknowledge and accept the extent of his deprivation and loss.

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One strategy used to promote letting go during IC or two-chair enactments involves saying goodbye to the imagined other, the relationship, or a lost part of the self. There seems to be universal recognition that this can be powerful and valuable for clients, and other approaches to grief therapy besides EFTT incorporate some variation on this procedure (see Neimeyer, 2016). In some cases, the process of letting go can be symbolized by inviting the client to list all those things that are now gone. For example, a therapist could prompt a client to “say goodbye to all the good things—what were they?” then to “say goodbye to all the bad things—good riddance to what?” and, finally, to “say goodbye to all the hopes and dreams—what were they? What is it that will never come to pass?” In the process of allowing pain and accepting loss, clients also shift to acknowledging and accepting the self as having been shattered and devastated by the loss and surviving despite this devastation. Moreover, there is an increased sense of self-control or agency in choosing to allow these experiences. One of the distinctive features of sadness expression, especially in contrast to anger, is its association with the experience of vulnerability. Tears of sadness are accompanied by relief, softening, and compassion toward the self and sometimes toward the other. Support New Perceptions of the Imagined Other Primary adaptive sadness is free of blame, and during IC, heartfelt expressions of sadness and longing can elicit (from the imagined other) responses of comfort, soothing, and possibly regret for causing the client pain. However, sadness and acceptance of loss may mean accepting the limitations of the other in terms of relationship quality. The client discussed earlier, for example, was able to accept that his father was incapable of love and felt sorry for him. In either case, when sadness is expressed to or about (as in EE) attachment figures, it almost always is associated with a softening toward the other (e.g., the client might say, “He did the best he could with what he had” or “She was a victim herself”). Monica, for example, was able to see her mother’s suicide as “a terrible mistake” stemming from desperation rather than self-centeredness and any lack of caring. Directing clients’ attention to what they imagine the other would feel “in their heart” rather than focusing on the other’s negative behavior can help elicit client empathy. This is distinct from minimization and making excuses for the other, as sometimes occurs in the early phases of therapy. Notice that, technically speaking, this involves a shift from using the imagined other as a stimulus to evoke a response in the self to promoting experiencing from the perspective of the other as a way of promoting empathic understanding. A shift to more realistic perceptions of the other is also illustrated by John, the client who had been placed in an orphanage after the death of his mother. Early in therapy, he had idealized his mother, viewing her as an “angel.” Deepening his experiencing resulted in a more authentic and less superficial experience and a richer understanding of her: THERAPIST:

Of course, at age 5, she was your angel, your world. But she was a real woman. Now, as a grown man, how do you see her?

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CLIENT:

I know she must have had problems; my uncles always said she was an addict, but I always felt loved by her. We used to sit around the kitchen table, and she would help me do my homework— stuff like that.

THERAPIST:

So, despite her problems, she loved you. . . . How tragic to lose her—heartbreaking.

CLIENT: [His eyes well up with tears.] THERAPIST:

Stay with that—she is worth your tears. What is the worst part of it for you?

CLIENT:

It makes me so sad to think of her suffering all alone. She was so young—sweet, really.

THERAPIST:

Yes, she sounds like a gentle soul. And you, her beloved boy, thrown to the wolves, also suffering alone.

Through continued exploration, the client was able to acknowledge the reality of his mother’s tragic life and experience deep compassion for her, rather than superficially idealizing her. At the same time, he was also able to feel compassion for himself, for his years in the orphanage feeling sad and alone, and the many other losses he had endured—his Indigenous cultural identity (not only lost but also demeaned), his family and childhood, his destroyed sexuality, his ruined health. Many survivors of complex trauma are in ongoing relationships with perpetrators of abuse and neglect, and this can obviously make resolution more complicated. For example, a client, Rachel, presented in Chapter 7, felt angry and betrayed by her alcoholic mother, who failed to protect her from sexual abuse at the hands of a babysitter. In their current relationship, the mother manipulated her daughter (the client) to get her own way. Her mother was unreliable and could not be supportive or play the role of a proper grandmother. All her life, Rachel felt that she had been “mother to her own mother” and lamented her unmet dependency needs. She “walked on eggshells” with her mother and engaged in endless efforts to please her. The therapist commented, “It’s as if, if you do just the right thing, your mother will finally wake up and see you and appreciate you.” The client laughed and said that she had been unable to accept her mother for who she really was. Therapy involved many sessions of exploring the impact of the mother’s current behavior on the client, the constant disappointments, what the client longed for, and the pain of never getting it. In desperation, Rachel also considered the possibility of ending the relationship entirely, and she explored both sides of this dilemma in a two-chair dialogue. This accessed deep sadness at all the dis­ appointments, letting go of the hope that things would ever change and accepting that her mother was incapable of meeting her needs. She was able to move on to explore alternative ways to get the nurturing and support she needed from others in her life. Finally, Rachel was able to feel compassion for

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her mother (“She can’t say it [referring to the mother], but she would be devastated if I ended it. She is like a child; she needs me”). Moreover, Rachel developed a clear sense that she, in fact, did not want to end the relationship. However, she became able to set limits in terms of the behavior she would not accept in that relationship. The latter was facilitated by expressing resentment (anger) at her mother’s unacceptable behavior and having this validated by the therapist.

INTERVENTION FOR OTHER TYPES OF SADNESS Not all sadness concerns interpersonal separation and loss. The following subsections describe EFTT intervention with self-related losses and depression that so frequently are associated with complex trauma. Accepting Self-Related Losses Trauma of any kind can result in numerous self-related losses, including alienation and isolation through the inability to communicate one’s experiences or trouble connecting interpersonally with others. In some sense, the horrors of trauma are locked up inside the individual. After fear is reduced, anger at maltreatment seems to be the adaptive experience most often associated with details of a trauma, whereas sadness is associated with the many losses that become so apparent in the wake of abuse and injury. These losses are frequently minimized or overshadowed by more powerful emotional experiences such as anger, shame, or fear, but eventually, they need to be acknowledged and grieved. Experiences of complex trauma, particularly in development, typically involve especially devastating losses to the self: a ruined sexuality or capacity for intimacy, loss of innocence and self-respect, and shattered hopes and dreams, as well as being deprived of basic attachment needs and the effects this has on adult functioning. When offenders continue to be viewed as unrepentant, despicable, and cruel, grieving these losses to the self is done in the context of the therapeutic relationship or in two-chair dialogues that involve expressions of sadness and compassion for the self (Chapter 9). These enactments can be used alone or in conjunction with IC or EE. For example, an earlier chapter described how Claire, the client who had been sexually molested by her brother, shifted between angrily confronting the imagined brother and comforting herself as a child. The therapist helped Claire access compassion for herself and develop self-soothing and comforting responses by asking, “Imagine her, you, that little girl who feels bad about herself. What do you want to say to her? What do you want her to know?” Other survivors of complex trauma have lost the capacity to connect interpersonally and are profoundly lonely. This is different from the primary adaptive sadness one feels simply from being alone and without adequate opportunities to connect to a social world. When one’s capacity to connect is compromised,

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this can be a function of deeper self-related issues of primary maladaptive shame. A client with a history of being emotionally terrorized and physically abused by her father and coldly rejected by her mother stated, “There was something odd about me as a kid,” and “I have failed in my efforts to connect with people.” Although she described herself as “climbing the walls” with loneliness, she found it difficult to acknowledge her emotional pain experientially. In an example of paradoxical sadness, her eyes welled up with tears at any sign of warmth or compassion from the therapist. Intervention helped her gradually acknowledge the extent of the deprivation she had experienced and the depths of her longing. THERAPIST:

These demonstrations of kindness seem to touch a big emptiness inside you.

CLIENT: [in a little girl voice, suppressing her tears] I don’t like it; it makes

me feel foolish. THERAPIST: Foolish? There’s nothing foolish about needing affection; it’s

like you’re starved for it. CLIENT:

I hate admitting this.

During IC with her mother, the client could express anger but not explicitly admit her unmet need for mothering, although her pain was evident. CLIENT:

I don’t want to want her.

THERAPIST:

Maybe not now, maybe it’s too late . . . but as a child?

CLIENT:

Oh, yes, as a child. I remember standing close to her and thinking how nice it felt.

THERAPIST:

Wishing for what—maybe a hug?

CLIENT:

Oh, God, hugs were out of the question!

THERAPIST:

How sad—little children need lots of hugs and kisses; it’s like food for the soul.

CLIENT: [sighs] Yes, well, I never got that food.

Interventions continued to focus on what it was like for this client as a child and helped her express sorrow about unmet attachment needs and her lifetime of loneliness. Still another client experienced regret about not realizing his career potential after growing up in an abusive environment. He was always fearful and nervous as a boy, did poorly in school, and as a child, believed he was stupid. The client also regretted his ruined marriages, which he authentically attributed to his own limitations, not in self-blame but rather as part of his accepting responsibility for contributing to the marital breakdown. This client initially minimized these losses (“I shouldn’t complain. I have a good job, right? I’ve even been promoted to supervisor; people respect me”). Intervention with this client validated his experience and helped him

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fully acknowledge the significance of his loss. For example, the therapist said, “Yes, you’ve accomplished a lot, despite your crappy childhood, but it sounds like you never had a chance to really try other things, test your potential. I guess the truth is many opportunities are gone forever; you’ll never know, and that’s what makes you sad.” This helped the client grieve and accept the reality of his lost career potential, let go, and consider new possibilities rather than maintaining his Pollyannaish stance. Working With Depression Depression can be a normal part of grieving that occurs in an early stage of that process and then shifts. Resolving depression that does not shift is typically the focus of Phase 2 of EFTT because it involves changing maladaptive processes that interfere with resolving interpersonal trauma. Other volumes describe emotion-focused therapy for dealing specifically with depression (e.g., Greenberg & Watson, 2006; Salgado et al., 2019). We briefly discuss therapeutic work with depression here to distinguish this process from promoting primary adaptive sadness at separation and loss, as described earlier. In terms of trauma, clients who were unable to protect themselves or loved ones can collapse into powerlessness, can feel numb, and are vulnerable to the reactivation of these feelings in their current life. Also, they may never have had an opportunity to express the sorrow they feel for their own and their loved one’s suffering. We have recently seen many refugee trauma survivors in our clinics, and depression is prevalent among these individuals. After the initial “honeymoon” and adjustment period that is focused on meeting basic needs for housing, school, employment, and learning English, they begin to miss their family and home and may have difficulty connecting and adjusting to their new life. These clients can also have difficulty accepting that they probably will never see their family and home again. They may hang on to that fantasy but then regularly lose hope when the reality of their situation sinks in. This was the case with a client whose family arranged for her to leave her home country after she had been raped and held for ransom on two separate occasions. She had no hope that circumstances in her country would change and, therefore, no hope of returning safely and seeing her parents again. She had also found it difficult to find appropriate work and new friends in Canada; things were not working out as she had planned. Each new dis­ appointment triggered a collapse into depression for her. In instances like these, depression is secondary, a by-product that follows more primary sadness about loneliness, separation, and loss. It can also be secondary to primary maladaptive shame or fear related to a sense of self as either bad or weak. This aftermath of sadness that continues as depression represents the inability to accept that a given loss is permanent and the related collapse into defeat. Here, loneliness involves both the primary adaptive sadness for her current isolation and separation but also entails elements of maladaptive emotion. When she collapsed into depression, she felt threatened and unable to cope with her new reality (i.e., maladaptive fear), which reflected an

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inability to integrate this reality into her new social world (i.e., maladaptive shame and alienation). Appropriate intervention is aimed at exploring and changing clients’ sense of defeat, meaninglessness, and inability to cope. This is done, in part, by validating and promoting expressions of primary adaptive sadness at very real losses. Although providing hope is an important part of therapy for complex and cumulative trauma, it must be realistic. Hopefulness cannot be clinging to impossible dreams and unrealistic expectations. Thus, intervention with clients who feel destitute ultimately involves helping them face their hopelessness and accept the reality of unavoidable separations and losses that are indeed beyond their control. Sadness is about endings and saying goodbye. The following chapter deals with ending therapy and the difficulties that may be encountered in the termination process.

12 Termination

T

herapy termination is about completing the resolution process, consolidating client changes, saying goodbye, and bridging to the future. The length of the termination phase varies depending on a client’s needs and the length of therapy, and it could range from one to several sessions. As in most therapies, when the number of sessions is time limited by the setting or client circumstances (e.g., financial resources), discussions of therapy ending take place long before the actual final session so that clients are well prepared. In the standard model of EFTT presented in this book, clients typically initially contract for 16 to 20 sessions. Before Session 16, we begin discussing client progress, their feelings about ending, and whether a few more sessions will be needed to wrap things up. For clients who are nervous about ending and losing the support of therapy, there is always the possibility of gradually tapering off sessions and returning for booster sessions. In our experience, termination is not a major issue for most clients who are suitable for short-term therapy, and agreement about the number of sessions and when to end is easily determined collaboratively and adhered to. However, termination is more complex when clients do not have control over the number of sessions (e.g., some agencies limit the number of sessions they can offer), therapy has continued for a longer term, trust was more difficult to cultivate, or the client is more vulnerable and has few external resources. Obviously, in these cases, provision for the continuation of services is essential. While termination must be more definitive in research studies on emotion-focused

https://doi.org/10.1037/0000336-013 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  279

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therapy for trauma (EFTT) and some clinics, private practice settings afford more flexibility. In this chapter, we describe how to revisit core issues and use a final round of imaginal confrontation (IC) or evocative exploration (EE) to help create closure and consolidate client treatment gains. We highlight that one of the aims in these concluding interventions is to emphasize clients’ new awareness of and ability to monitor and control their internal processes. We also provide guidelines for giving and eliciting mutual therapist–client feedback about the process and experience of therapy. Finally, we discuss difficulties that may emerge at the end of treatment in EFTT, especially in time-limited situations. We end with some remarks on bridging the work clients have done in treatment with their future lives.

COMPLETION AND CONSOLIDATION OF CHANGES Explicitly reviewing client changes at termination helps consolidate those changes, assesses the degree to which goals have been accomplished, and identifies areas for further growth (either in or outside of therapy). This end-oftreatment discussion focuses on changes in self-related processes and in relation to those significant others who were the focus of therapy. Final IC or EE A final IC or EE with the imagined others who have been the target of therapy normally takes place one or two sessions before what has been agreed will be the final session. Complete and Bring Closure to the Resolution Process The purpose of the final IC (or EE) is to help the client move forward toward resolution as much as possible, tie up any loose ends, and bring closure to the resolution process. The therapist might say, for example, “How do you feel about ending, saying goodbye to her? Is there anything else you want to say to your mother before we end?” Before the session in which the final dialogue with the imagined other is initiated, it is important to review client goals. Therapists must be clear about their clients’ degree of resolution (see the Degree of Resolution Scale in Appendix C) and clear about what still needs to be, and feasibly could be, accomplished in one final dialogue with the imagined other. For example, even though forgiveness previously may have been stated as a goal, the client may still be unable to forgive the other. In such a case, the focus of the final IC would be to explore what interferes with forgiveness, what is required to accomplish that initial goal, or whether the goal can be revised. One strategy in promoting forgiveness (or at least in increasing understanding) of the other could be to pay particular attention to client enactment and perceptions of the other and promote experiencing from the other’s perspective to elicit client empathic resources. An alternative

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strategy might be to help clients explore any lingering anger they may have that interferes with understanding the other’s perspective, something we discuss in more detail later. Even though the final dialogue is an opportunity for promoting closure, the therapist should also be prepared for new information to emerge. Clients see this as their last opportunity to work through issues that have been the focus of therapy and may have given this considerable thought before the session. This reflection and preparation are helpful to the process, and therapists may want to encourage clients to revisit their goals considering the treatment process that has passed. For example, one client had been firmly entrenched in a completely malevolent view of his brutally violent and abusive grandfather, who was his caregiver for several years. During the final IC, however, he imagined the grandfather in heaven, remorseful but also so prideful that it prevented him from apologizing. The client imagined that his grandfather was only able to say, “I wish I’d been a better husband to your grandmother— she was a good woman—and a better grandfather to you.” This imagined response felt authentic to the client, and he was able to let go of his anger and close the interaction satisfactorily. In an interview several months after therapy, this client reported continuing to feel fully resolved. However, many clients express concern that they will not be able to maintain gains once therapy is over. This was the case for one client who had made considerable gains in assertiveness and boundary definition with her controlling and domineering mother. In the following excerpt, the therapist directs the client’s attention to her adaptive relational needs and asks her to imagine saying “no” in a situation she had described in an earlier session when she had acquiesced to her mother’s demands. CLIENT:

I want what I say to be taken seriously and not just pushed aside. I’m an adult.

THERAPIST:

So, what are your needs at that moment—to be respected, not taken lightly?

CLIENT:

I want to be in control of what I want to do, and that’s it.

THERAPIST:

That sounds legitimate to me. How would you say that to her, imagine her in that situation?

CLIENT: [pauses] Please respect my wishes. When I say I don’t want

something, I mean I don’t want it! THERAPIST: I’m in charge. [Client: Right.] I know what I want and don’t

want. What else about guarding your boundaries? CLIENT:

I want you to take what I say seriously, take my choices seriously.

THERAPIST:

It’s my choice. What I think is important. [Client: Yes.] So how would Mother react?

CLIENT:

Oh, excuuuuse me! That’s it, and then I would get upset at her digs.

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THERAPIST:

She is digging, carving a hole in your boundaries.

CLIENT:

Wait a minute! I’m allowing that to happen!

THERAPIST:

So, now?

CLIENT:

I would not allow that to happen. I would ignore her or just say again what I want.

THERAPIST: Okay, I hear you don’t want to get in a power struggle with

her. [Client: Right, exactly.] But she says, “Excuuuuse me,” and you feel the dig. Now how do you react? CLIENT:

Come on, Ma, I’m a grown woman. Please respect my wishes. I’m not doing it to hurt you. I’m doing it so you respect my choices.

THERAPIST:

Right now, what is going on for you inside?

CLIENT:

I feel really good.

THERAPIST:

Can you be more specific about that feeling because it’s really important; you’ve been stuck for a long time.

CLIENT:

I have no anger, no turmoil, no conflict. I feel like I’m in control now, in control of my emotions, in control of my decisions.

Here, the client has clearly achieved Level 6 on the Degree of Resolution Scale (see Appendix C) in her view of herself as more autonomous and powerful. In other cases, new issues spontaneously (and unexpectedly) emerge in the process of completing the final interaction with the imagined other, and these issues need to be worked through. A good example of this was the final IC with Monica. Before this session, it appeared that issues with her mother were fully resolved, but when encouraged to say goodbye to her mother in the final IC, she was unable to do so. This raised the issue of her attachment to her internalized mother that needed to be explored. In exploring this issue, the client expressed her deep need and longing to feel that she had been loved by her mother and her insecurity about this. The discussion that followed with her therapist elicited poignant and comforting memories for Monica when she was a girl interacting with her mother. These experiential memories strengthened the attachment to her internalized mother and fulfilled these unmet needs in a healthy and realistic way so that she could let go of the longing and move on with her life. Consolidate Changes Improvements in complex traumatic stress are more than simple symptom reduction. Furthermore, shifts in personal meaning and attachment to abusive or neglectful others are challenging to measure in a concrete way. To that end, the final IC or EE is intended and explicitly framed as an index of change, a performance-based measure in which therapist and client can

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witness how the client reacts differently. This is an opportunity for clients to experience their present status in relation to the core issues that brought them to therapy (e.g., the therapist might say to a client, “Let’s see where you’re at with your father. Tell him how you feel about him and those past issues now. What’s your current understanding?”). Therapists can also encourage clients to compare their present state with that of the beginning of therapy (e.g., “Pay attention to how you feel now compared with how you felt at the beginning. Maybe even tell your father how you have changed”). This increases clients’ awareness of their current position and what has been accomplished over the course of therapy. It also orients clients by increasing their awareness of areas still requiring attention and future growth. Different Kinds of Resolution for Complex Trauma The individual shape that interpersonal resolution will take for a given client is not evident at the beginning of therapy. Helping clients work through complex narratives about the historical past begs for some “ending” to the relational story, which is not necessarily the case for clients being treated for depression or anxiety alone. The solution one arrives at vis-à-vis one’s perpetrator is both personal and a relational and social act (explicitly or implicitly). Resolving issues of childhood maltreatment always involves holding perpetrators rather than the self appropriately responsible for the harm. Resolution can also end in either forgiving the relational transgression or betrayal or not. Similarly, one can either also reconcile with the other person, building a newly repaired relationship, or not. As we detailed in Chapter 10 on anger, early research (Chagigiorgis & Paivio, 2006) on EFTT indicated that less than a quarter of clients achieved resolution by forgiving their perpetrators. When forgiveness occurred, the abusers in question tended to be neglectful caregivers and mothers whose fault was not adequately protecting the client as a child. However, even in the subgroup of forgivers, there was considerable variability. Some met research criteria for forgiveness (i.e., both reduced hostility toward and increased separation from perpetrators) but did not actually use that term— suggesting the forgiveness construct, per se, was not important to them. Some clients who met the criteria for forgiveness also reconciled and felt positively toward the other person, while other clients did not. The latter (i.e., “forgive but don’t forget”) essentially let go of their grudge and their right to restitution, but they chose never to return to any kind of closeness or vulnerability in that relationship. However, a little over three quarters of clients in the EFTT study who resolved issues with perpetrators never forgave them (Chagigiorgis & Paivio, 2006). Perpetrators in these instances were typically abusive, cruel, predatory, and unremorseful. This nonreconciliation and nonforgiveness nonetheless involved a dramatic change in how a client viewed their perpetrator. Rather than powerful and dangerous, the client came to see that person as weak, sick, even

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pathetic, and deserving of punishment (justice) whether they received it or not. Because the form that resolution can take is nebulous in the early phase of therapy, being aware of viable solutions to complex relational trauma can help focus the treatment as one approaches termination. These are like goalposts for treatment outcome, marking the general direction to help clients articulate the specific solution that fits them best. Client Awareness of Changes in Internal Processes Self-related goals in EFTT are to help clients better tolerate emotional pain and self-soothe, stand up to critical self-statements, and be more confident in relation to others in real life. Basic EFTT intervention principles apply in consolidating these client changes. As described in Chapter  2 on the treatment model, in “change” narratives, clients report discoveries about the self and relationships and report new outcomes at the termination phase of therapies, including EFTT (Angus et  al., 2013; Paivio & Angus, 2017). It is important that therapists not only acknowledge these positive changes but also take the time to help clients attend to and deeply experience them. For example, when clients report that they generally no longer feel so anxious, the therapist typically asks them to recall a particular situation and describe how they now work through feeling anxious (e.g., “Can you think of a situation in which you felt anxious and then calmed yourself? What went on inside? What did you do or say to yourself?”). Therapists also empathically respond to clients’ feelings (e.g., pride, confidence) concerning their changes and accomplishments (e.g., “It must be such a relief to be free of that constant pressure,” or “Your smile tells me something feels good about all this!”). In the following example, the client presented earlier reported new assertive behavior with her domineering mother. The therapist invited her to elaborate on her internal experience. THERAPIST: Let’s go there. What happened that you were able to say no

when before you struggled? CLIENT:

Yes, now I am not going to rearrange my life to handle her problems. I set my boundaries and priorities there, and she didn’t argue at all. I was pretty pleased.

THERAPIST:

Exciting—you were clear, knowing what you want. And people around you are responding. What is your understanding of that?

CLIENT:

Because I am saying it. The problem was I was keeping things inside; no one knew what was bothering me or where the boundaries were, and now they see.

THERAPIST:

So, being able to say where you stand is critical.

CLIENT:

I feel confident, strong, respected.

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In the following segment, the therapist continues to explore positive change and celebrates the client’s success with her, both of which contribute to consolidating change. THERAPIST: If you were to describe what is different, where this new

confidence comes from? CLIENT:

Because I am able to verbalize and am actually sure of my feelings, not all over the place . . . I know my identity . . . I’m learning more about me.

THERAPIST:

That’s exciting.

CLIENT:

What’s more exciting is to know my body signals, feelings, and what I should do about them.

THERAPIST: Tell me about some of those signals. CLIENT:

Like today, when my mother asked for money, usually I feel guilty, sad, upset in my gut. Today I felt calm, inclined to help, and when my husband said I should not give her money, I was getting upset, but I was aware, processed the information from my body, and I did it quickly. I didn’t have to think about it for hours.

THERAPIST:

So, you listened to your body; this allowed you to be in control, not all hurt [Client: Yes.] That is incredible. I’m so excited to hear that. That is exactly what we are trying to do here, increase awareness.

Importantly, a client’s therapeutic gains are always genuinely framed in terms of accomplishments and mostly attributed to the client’s efforts. For example, during the last session, a therapist stated, “You must feel pretty good about what you’ve accomplished. You’ve ‘come a long way, baby!’ [They both laugh.] Seriously, you’ve worked very hard.” At the same time, of course, clients will frequently recall something meaningful that the therapist said or did, and it is important not to dismiss this. Therapists openly accept their clients’ compliments and appreciation of their contributions but acknowledge the collaborative nature of the process, highlighting that “we did it together.” In any case, the implicit message to be communicated is, “You are the sort of person who can forge a collaborative relationship and make use of what therapy has to offer.” This not only enhances self-esteem but also increases the likelihood that clients will seek out support in the future, should they need it.

AWARENESS AND ACCEPTANCE OF LIMITED CHANGE In some instances, clients do not fully achieve their treatment goals and aspirations. The following subsections describe strategies for addressing this during the termination phase of therapy.

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The Client Is Disappointed About Limited Gains or the Degree of Resolution Unfortunately, clients (and therapists) do not always achieve what they had hoped for in therapy. First, it is essential for both parties to have realistic expectations for change throughout the therapy process. Goals should be circumscribed (particularly in short-term therapy) and realistically attainable. Clients can reasonably expect to make meaningful improvements in at least one or two important areas. If the client perceives that this has not occurred (and will not occur), their disappointment needs to be discussed and processed as therapy approaches the final session. For example, clients might be bothered that they still feel angry and unable to forgive a parent or other offender, feel insecure in a current relationship, or wrestle with depression. Creating meaning around this disappointment helps soothe it and sometimes can advance the resolution process a bit further still. Assuming the current course of therapy has come to an end, the basic intervention strategy is to acknowledge and explore client disappointment and promote acceptance of “what is” and self-acceptance in this area. Therapists can communicate that they sympathize with the client’s disappointment (e.g., “Yes, I wish you could feel completely at peace with this, but that’s just not where you’re at right now, is it? You can’t force yourself to be someone you’re not, feel something you don’t feel”). Interventions also promote clients’ experiencing to explore and help them understand their current position vis-à-vis their struggle for closure. Whatever the case may be, interventions must instill confidence in the client’s capacity for continued growth and hope for the future (e.g., “The important thing is to continue paying attention to and trusting your experience. Be open to whatever comes your way, just as you did in therapy. Trust that if you do this, things inevitably will evolve”). Thus, the aim of interventions in this last phase is to acknowledge the status of changes to date and the current circumstances while providing clients with a sense of direction for continued personal growth. Client Changes Appear to Be Pseudoresolution Pseudoresolution of issues with offenders typically is characterized by clients’ assertions that they have resolved their issues and are “over it,” while their therapists have concerns that this may not be entirely the case. For example, client wishful thinking can occur, especially when there is ongoing interaction and desired reconciliation with an offender who is an attachment figure. Sometimes clients seem to have achieved a high degree of resolution during IC or EE, but when they interact with the other for the first time in real life, this is completely undone, and they are profoundly disappointed. Pseudoresolution also can occur in cases when clients, for moral or religious reasons, want to bypass anger and quickly move into forgiveness. In other cases, client expressions of acceptance and letting go of expectations regarding the other are accompanied by a disappointed shrug that is more like defeat and resignation.

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In still other cases, client separation from the other is characterized by cold, hostile distancing (e.g., when a client says, “I don’t give a shit about him anymore. He is dead to me”) that is more characteristic of the earlier rejecting anger stage of the process. If not addressed, all these situations can result in premature termination and relapse. Intervention to address pseudoresolution involves challenging clients’ perceptions of resolution without invalidating their underlying experience. This typically involves clearly differentiating between “the changes I genuinely wish, hope, and strive for” and the “changes that have indeed occurred to date.” Therapists also need to anticipate and directly address possible client dis­ appointment. For example, one client desperately wanted to reconnect with his alcoholic father, who had abandoned him and his mother when he was an adolescent. Interactions with his imagined father during IC were poignant and genuine. He expressed forgiveness and enacted the father as regretful and wanting to make amends to his son. At one point in his therapy, the client had arranged a live meeting with his father, during which he intended to confront past issues and address them in real life. The therapist was concerned that the client might be setting himself up for disappointment because of his deep longing, combined with information suggesting the father might have a limited capacity for responsiveness. So, the therapist opened this up for discussion by noting, “I wonder if there is a bit of wishful thinking here, that you want very badly to reconnect with him, but you might be setting yourself up for disappointment?” They then discussed possible scenarios involving the father and how the client might handle them. Similarly, in situations of client resignation or resentful distancing from the other, interventions involve making tentative observations about these processes. For example, the therapist might say, “I know you would like to just accept her for who she is and move on, but I hear a kind of resignation in your voice, like giving up rather than acceptance,” or “I hear a lot of anger still in your voice—not that you can’t be angry at times—but it seems like he still has the power to affect you in a negative way.” After such an introduction, clients are then invited to explore the issue further. The therapist may also provide the client with information about the jagged process of resolution and validate common sources of difficulty. In the end, either more sessions can be offered to move the process forward, or clients can be helped to be more realistic and accept that they are not as fully resolved or at peace with the other as they would like to be. Of course, therapists also need to ensure that they do not push the client into pseudoresolution because of their desire to help, hurry the process, or be successful at promoting change. Therapists also need to accept the reality of what is.

SHARING MUTUAL FEEDBACK The following subsections specify the types of feedback that are appropriate for both the therapist and client, considering the different roles they have in therapy.

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The Therapist Gives Feedback to the Client Therapists are experts on trauma and the processes of therapy. Their feedback, therefore, should concern their observations of therapy processes, not clients’ reported changes in their lives. Therapist feedback is always in relation to the presenting problems and client goals identified at the beginning of therapy and how these have evolved over the course of treatment. It is essential that therapists review their case notes and think carefully about the client and case before giving this feedback in the last session. Feedback should be specific and, if possible, should refer to specific phases of therapy or sessions and content. The most obvious areas for feedback and discussion are the client’s process and degree of resolution with offenders, as well as any therapeutic relationship issues that arose during therapy. Therapists can refer to the Degree of Resolution Scale (see Appendix C) for guidance in relevant dimensions of resolution for feedback. One might comment, for instance, on the degree to which a client’s feelings were avoided or inhibited or whether key adaptive emotions have been experienced and expressed. Other useful points for feedback include the core existential and interpersonal needs that may have been recognized and valued by the client and any changes in their perceptions of the self and other. These changed perceptions include new insights and understanding expressed during therapy, as well as the accompanying affective qualities that a therapist observed a client express in sessions (e.g., reduced anger toward the other, increased detachment or calm when confronted with trauma memories, feeling less needy for the other’s approval, increased self-confidence and self-acceptance). Other observed processes that might be the topic of therapist feedback include clients’ emotional functioning and narrative quality features that reflect trauma resolution. Relevant aspects of emotional functioning include clients’ attention to affective experience (or cognitive style, if this was an issue), their capacity to explore their internal experience and use this to solve problems, or their capacity to make sense of and work through issues. In one instance, the therapist commented, “I noticed you became much calmer. Remember? You were quite agitated at first, and then you got really good at expressing your true feelings—your resentment toward your mother, for example—and really clear about your boundaries with her.” In another case, the therapist reflected, “You were willing to wrestle with those difficult feelings and come to understand your father’s limitations and, at the same time, not let him off the hook.” Other features of narrative quality that can be topics for feedback include clients’ clarity and coherence in talking about trauma, as well as their confidence and conviction in expressing feelings and needs or in stating their opinions and perspectives. Observations about clients’ narrative styles could further include the fact that clients are focusing more on the present and future than the past or their references to positive feelings. Of course, none of this should be news to the client. This type of feedback should have been provided directly through process observations and reviewing goals or indirectly throughout therapy. Thus, the last session is a summary, a take-home message that captures the client’s process developments and any observed areas of

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clients’ disappointment about achieving their goals and areas for further growth. In bridging to the future, therapists help clients identify ways in which they can address their remaining challenges. In terms of relationship issues, therapists need to highlight any observed struggles the client had in cultivating the therapeutic alliance (e.g., “I saw how difficult it was for you to come in here and share those painful things with a perfect stranger”). Moreover, it is important to highlight client strengths in meeting those challenges (e.g., “I saw how dedicated you were—never missed a session—and how hard you worked to push through your fears”). Acknowledging clients’ efforts and strengths in confronting their difficulties again contributes to their self-esteem and self-confidence. This is another place where therapists can refer to the positive feelings associated with the attachment bond and collaborative process (e.g., “I was aware of what a relief it was for you when you finally were able to share that with me [identified specific incident],” “I was aware of how good it felt to connect on a deep level”). If appropriate, therapists can disclose their experience of the relationship (e.g., “I really appreciated your willingness to be vulnerable with me—I felt very close to you,” “It was a real privilege to be let into your life”). These personal exchanges can contribute to clients’ appreciation of healthy attachment and seeking it outside of therapy. The Client Gives Feedback to the Therapist Clients are the experts of their own experience. Therefore, therapists will elicit clients’ feedback concerning those facts of their lives and internal experiences that only they have access to. This includes asking clients about areas of growth (positive outcomes from working through the trauma), current functioning and coping in their daily lives, and their changed views of the self and others. Another important area to elicit is clients’ feedback concerning helpful and hindering aspects of therapy and the connection between therapy processes and improvements in their daily lives. The therapist should probe for specificity of examples and situations; not only is this useful information for the therapist to improve their practice, but such specificity also contributes to consolidating client gains. Moreover, by doing this, clients come to contemplate “what worked for them” and identify the kind of support or opportunities that they might further seek out in their lives. In addition, for individuals who have felt ineffectual, helpless, and needy for much of their lives, it can be particularly meaningful to feel that their opinions are appreciated and valued and have an opportunity to give back.

DIFFICULTIES WITH RESOLUTION Clients can get stuck at any stage in the resolution process. Sometimes difficulties are partly attributable to persistent self-related disturbances (e.g., difficulties with experiencing, fear and avoidance, entrenched feelings of worthlessness) that now, in turn, interfere with the resolution of relational difficulties. In these cases, it is necessary to return to processes that were the focus of therapy in

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Phase 2, and treatment will likely be prolonged. We now focus on difficulties that are typical of the termination phase of therapy and that can be addressed in a few additional sessions. The Client Has Difficulties Letting Go of Anger and Sadness The client may have difficulties with the final steps in the resolution process (see Exhibit  6.1) that takes place during Phase 3 (Chapters 10 and 11). In terms of sadness, although one may want one’s clients to accept irrevocable loss and move on, it is important not to push for premature acceptance. This is consistent with a fundamental intervention principle of helping clients accept their experiential reality. When clients have difficulty letting go, effective therapists help them attend to that experiential reality and accept that they “cannot say goodbye right now—maybe someday, but not now.” In some instances, interventions of this kind involve supporting clients’ need to hang on to hope, for example, that a relationship can still be repaired or that they can return to their homeland, even if it seems like a fantasy. In instances of irrevocable loss, interventions should heighten clients’ awareness of their resistance and explore the block to letting go and saying goodbye. For example, the therapist observed, “So, it’s almost like you are saying, ‘I refuse to accept . . .’ Can you try saying it like that, explicitly—just as a way of exploring this?” The client complies: “I refuse to accept . . .,” and the therapist asks, “How does that sit with you?” The client Monica did not want to say goodbye to her dead mother because, to her mind, it meant losing her mother completely; she wanted to maintain connection and keep the (internalized) relationship alive. Contemporary views of grieving focus on constructing a new self-narrative, one that includes a new, changed, internalized relationship with the lost loved one (Neimeyer, 2016). So, in this spirit, Monica’s therapist highlighted her desire to maintain connection and asked her to elaborate on the importance of this to her. Monica explained that she felt her mother was part of herself, and she had always wanted the memories back that had been destroyed by the trauma, memories she found comforting. In this case, intervention supported the client in her wishes: Her “internalized mother” would always be with her, she could always turn to those memories for comfort, and this understanding became part of the resolution. In other cases, a client might say goodbye to a malevolent other as a way of detaching from influence, control, and emotional pain. Of course, setting boundaries and severing ties in this way will more likely emerge from the experience and expression of anger than grief. In either case, saying goodbye means weeping for and accepting what is lost forever and being open to constructing a new internalized relationship with the other. To let go of anger, it is important first to recognize that issues of dependence and struggles with separation may be partly a function of a client’s developmental stage or underlying personality pathology. For example, a young client was hanging on until the end of therapy, hoping for an apology from her mother that might never come and hoping her mother would change

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(“I wish she’d get into treatment”). The client’s desperate “wishfulness” and persistent focus on the offending other were a function of both the nature of her injury and her youthful naivete. One useful strategy in addressing this kind of obstacle is to validate the importance of those wished-for changes while at the same time increasing the client’s awareness of the futility of that effort. This can be done through the exaggeration of neediness, by the therapist role-playing the other’s refusal to change, or by directing the client’s attention to implicit maladaptive cognitions. For example, the therapist might say, “It’s like you can’t live until she changes [or apologizes]. You can never be happy. You’re doomed to live a painful and unfulfilled life.” Even if the client cannot let go of these unrealistic hopes and move on, interventions like these highlight the direction for future growth. Another client felt neglected by her parents and attempted to force them to pay more attention by “punishing them” in her daily life through various passive–aggressive behaviors (instrumental anger), to no avail. She was unable to accept that she would never get what she wanted from them and that they would never change. She also had difficulty enacting her parents in IC or imagining their point of view. Acceptance only began when the therapist enacted what seemed to be the implicit message from the parents: “We are never going to give you what you want; you can kick and scream all you like, but we are never going to give you what you want.” This brought the futility of her efforts into full awareness. She experienced the realistic hopelessness of her situation and broke into tears. This was the beginning of letting go. The Client Has Limited Capacity for Empathy With the Imagined Other Sometimes clients are unable to let go of unmet attachment needs and resolve issues with offenders because they are unable to imagine the other’s perspective or access personal empathy for them. The other remains the “bad object”— perceptions of them remain undifferentiated and globally negative. In these instances, intervention should explicitly promote experiencing when the client is enacting the other during IC. However, empathy training in this way will not work and will seem invalidating if the client’s limited capacity for empathy is a function of narcissism and a fragile sense of self. Therapy, under those circumstances, will likely need to focus on processes that are typical of an earlier phase of therapy. Specifically, empathy in the therapeutic relationship should be used to strengthen the client’s sense of self. Successful resolution with such clients will also likely require a longer course of therapy.

DIFFICULTIES WITH THERAPY TERMINATION In addition to having difficulties resolving issues with attachment figures, clients also can have difficulty letting go of therapy itself, especially when therapy is time limited and termination is not in their direct control. The following subsections describe how to address these difficulties.

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The Client Is Afraid of Termination Because the capacity for interpersonal connectedness is frequently disrupted by trauma—particularly complex relational trauma—clients should be encouraged early on to cultivate social support outside of the therapy session. Nonetheless, many clients still have impoverished social support networks and can find it difficult to let go of the intimacy and support provided by therapy. In most instances, fear about termination will be partly related to a client having limited external resources. Therapy can be gradually tapered off for vulnerable clients who fear they will be unable to cope without regular support. Of course, therapists need to ensure that clients have alternative coping resources and strategies for handling distress, and these issues need to be explicitly discussed in anticipation of termination.

The Client Is Angry or Sad About Termination Clients’ reactions to the therapist’s role in terminating treatment will likely reflect the nature of the issues they struggled with in therapy. Although this is essentially transference, EFTT therapists do not usually confront clients with transference interpretations but rather address their real experience of the relationship ending by way of a genuine interpersonal encounter. One client struggled throughout therapy to overcome general issues of anger and distrust and wrestled, specifically, with being vulnerable with his therapist. Eventually, however, he was able to be vulnerable with her. He came to appreciate the intimacy, feeling attended to and deeply understood. He had never previously had this type of intimacy and longed for it. As the last session drew closer and ending therapy was being discussed, he said angrily, “You don’t really care about me. This is only a job.” In situations such as this, immediacy and genuineness in the relationship are the first treatment priority, along with other basic emotion-focused therapy intervention principles. The therapist acknowledged and then bypassed the client’s (secondary) anger and responded instead to his openness and disappointment (primary sadness) that therapy was ending, considering that it took him so long to open up. This led to a discussion of the importance, to the client, of being himself and feeling accepted, and the therapist validated, “It must be hard to let this go.” After getting angry, the client initially minimized his dis­ appointment (“I know you’re a professional; you can’t keep seeing people forever”) but eventually apologized for his anger (“I know you really are a kind person, you really want to help”) and, in the end, acknowledged his loneliness. Together they discussed how the client could begin to get his intimacy needs met in his current life (e.g., allow himself to be appropriately vulnerable in other relationships rather than react with anger, as he had just done in the session) and how he could cope or endure in the absence of an intimate relationship.

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For other clients, ending therapy will be perceived as a tremendous loss. For example, one refugee trauma survivor had found it difficult to connect inter­ personally in her new life, and apart from her employment, she was extremely isolated. In session, she was open and vulnerable about her loneliness and longing for home, but therapy was sporadic, and she frequently canceled sessions because of her changing work schedule and the demands of child care. When the therapist suggested termination, assuming that therapy was not that important to her, the client struggled to stifle her tears. When the therapist empathically affirmed her vulnerability and encouraged her to disclose, the client wept openly, saying that she would miss the therapist and that she had no one else she could talk to. The suggestion of termination was perceived as another loss that the client could not bear. The therapist responded with compassion and apologized for underestimating the client’s degree of vulnerability and need for support, and they collaborated to continue therapy despite unavoidable disruptions in the process. The Client Relapses in Reaction to Termination A client relapse in reaction to termination must follow a relatively productive process of resolution, thereby differentiating it from complications related to premature termination. Normally, the possibility of relapse (following resolution) is discussed with the client, and further sessions are presented as an option should relapse occur. However, for some clients who have become dependent on therapy, symptoms can increase, and crises emerge just as therapy is ending. One client with a history of aggressive and self-harm behavior in response to rejection became highly distressed as therapy was ending and expressed fear that he would hurt himself or his girlfriend (who had been one focus of therapy). Treatment goals shifted to managing this crisis, and termination was deferred. The intervention included giving the client emotion regulation and distress tolerance exercises as homework and processing these in session using a more behaviorally oriented style (for examples, see Linehan, 2015). This was combined with helping the client explore feelings of insecurity and fear of abandonment at the prospect of therapy ending. When termination is deferred in this way following a symptomatic reaction (despite a productive course of treatment), it is useful to follow two guidelines. First, the client and therapist should explicitly verbally contract to extend treatment for a specified number of sessions rather than making an open-ended deferral. To that end, it is likely not in the client’s best interest to allow additional subsequent deferrals of termination. The reason for this is to avoid creating circumstances that reward clients (i.e., with additional sessions) for their expressions of distress (i.e., relapse). Second, the treatment goals in these new sessions should explicitly shift to symptom management and exploration of meaning, specifically regarding termination. This ensures that clients are better prepared for the termination that is to follow.

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BRIDGE TO THE FUTURE Bridging to the future includes discussing the connection between therapy processes and the client’s current life. Discussions may include, for example, the impact of interventions to reduce avoidance or self-criticism on current self-confidence and self-esteem or the impact of processes during IC on current relationships. This aspect of termination also includes a discussion of clients’ ongoing struggles and coping resources and, most important, their hopes and plans for their future. It is useful to also provide clients with frank information on a typical pattern of client recovery and the nature of relapse. As a preventative measure, therapists should encourage clients to consider the possibility of relapse. For example, the therapist might say, It’s wonderful that you have really been able to make use of our work together. But you and I know that life has its ups and downs. So, one day something might happen, and this stuff might raise its ugly head again. What do you think could go wrong or might be most distressing? What sorts of things will be useful for you when that happens?

It also is useful to normalize the future possibility of the client wanting to return to therapy. Therapists should express a willingness to “keep that door open” or refer to termination as “ending therapy with a semicolon rather than a period.” This assurance can serve as a preventative factor against relapse, regardless of whether clients make use of it. In one example, a young man who had successfully worked through issues related to family sexual abuse terminated treatment without difficulty but then recontacted the therapist less than a year later. His personal growth had led him to go further and consider the abuse that his siblings had also suffered, and he reported feelings of guilt over not having protected them (“It’s like now that I’m clearer about all this in my head, I want to rekindle family relationships and fix my love life too”). The therapist agreed to resume brief treatment to focus on current relational issues. However, after only four sessions, the client was again ready to terminate, saying, “I don’t know; I guess I am doing okay. As long as I’m doing my part, I’m okay with them [his siblings] not really reciprocating after all. It just doesn’t seem so much of a problem as it did a month ago.” Still another client, who had addressed issues of abandonment and neglect, found terminating therapy to be an especially daunting task. The client expressed a wish to “take the training wheels off really, really slowly.” So, the therapist and client agreed to taper sessions over a longer period posttermination, which included two booster sessions at 3-month intervals and then a final session that followed 1 year later. Moreover, it was important to the client (and feasible to the therapist) to firmly schedule the last appointment a full year in advance. For this client, the assurance that the “door is still open,” in the form of a concrete promise of an appointment, was enough to provide a sense of security and solidarity that fostered hope and continued personal recovery.

Afterword

D

espite increased attention in the media, the criminal justice system, and professional literature, childhood maltreatment remains disturbingly common. These childhood experiences are recognized as risk factors for virtually every adult psychiatric disorder. Thus, there is a need for effective treatments to address these client problems. There is abundant clinical wisdom in the field of trauma, and exciting new treatments are emerging—somatic approaches (Ogden & Fisher, 2015), psychedelics (Krediet et al., 2020), and adjunct and complementary treatments (Smith & Ford, 2020), for example. This book adds to these resources, giving clinicians additional tools for helping their clients and thereby giving clients new tools for problem solving, healing, and continued growth. Intervention strategies described in this book are intended to help clients value their feelings, perceptions, principles, and needs. The intention of this treatment approach is also for clients to feel compassion for their suffering and respect for their strengths, develop or renew trust in others, and turn to others for the support they may need. We hope that this book will contribute to those processes. We have intended for this book to be accessible to those who seek to learn new, sophisticated interventions in working with complex trauma. We have provided a lot of “how-to” specifics and included in-session details such that clinicians might, in some sense, recognize their own clients in these pages. For those who are new to an emotion-focused approach, being familiar with the relevant phases of therapy and the emotion markers described in this

https://doi.org/10.1037/0000336-014 Emotion-Focused Therapy for Complex Trauma: An Integrative Approach, Second Edition, by S. C. Paivio and A. Pascual-Leone Copyright © 2023 by the American Psychological Association. All rights reserved.  295

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book will help orient them to their clients’ moment-by-moment emotional processes. By acquiring a basic knowledge of the patterns of productive process and heightening one’s perception of a client’s shifts in emotion, as we have described, this model can be used to inform intervention—the types of empathic reflections or procedures that would be most fruitful at a given moment in therapy with trauma survivors. Because psychotherapy has entered a second and third generation of integrative treatments, we believe this book will also be useful to seasoned therapists who are already expert in another approach to trauma therapy and want to expand their repertoire. In short, we do not intend emotion-focused therapy for trauma (EFTT) to be implemented in a formulaic way but rather that its ideas and principles be integrated into therapists’ personal style and existing practice.

CONTEXT The EFTT treatment model presented in this second edition has developed in the context of theory and research in the field of trauma and other emotionfocused therapies. Research in affective neuroscience and on trauma has played a particularly important role in helping us understand how abuse and neglect harm individuals. Neuroimaging studies (e.g., Lanius et al., 2004; Neria, 2021) and emerging research on epigenetics and the transgenerational transmission of trauma (Yehuda & Lehrner, 2018), for example, provide a new understanding of the problems faced both by individuals who are suffering and the therapists committed to providing treatment. However, although critically informative, affective neuroscience and brain imaging will only be able to help clinicians address complex relational trauma insomuch as there are sophisticated theories of emotion and of psychological functioning to interpret those findings. For this reason, we believe that emotion-focused theory and the process research that supports it are important in mediating and interpreting relevant research on the neural substrates of trauma and recovery. To be effective, new directions in understanding trauma must inform what therapists do in session and in the context of a compassionate and deeply empathic therapeutic alliance; we believe the conceptual framework presented in this book will help practitioners do this. EFTT is a development of emotion-focused therapy. It comes from an experiential and humanistic tradition that, from its inception, has been uniquely informed by professionals seeking to integrate science and therapeutic models. As a result, the theory and intervention principles of this specific treatment model have developed, collectively, in the context of a larger body of emotionfocused therapy research, what is perhaps the most comprehensive research program on emotional processes in the field of psychotherapy. To date, there is a large body of research and practice supporting emotion-focused therapies applied to a variety of disturbances, including depression, generalized anxiety,

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social anxiety, personality disorders, couples, and families (see Greenberg & Goldman, 2019a). All these disturbances have been linked to a history of complex trauma. Work on EFTT over the past 20+ years has reciprocally been informed by and informed these developments.

EFTT: PAST, PRESENT, AND FUTURE Because of the affect revolution that is occurring in both psychology and neuro­ science, the old dichotomy of “feelings and arousal” versus “thoughts and meanings” is viewed as overly simplistic and untenable. For this reason, experiential, emotion-focused, and somatic-focused therapies are rapidly developing treatment approaches that, now, are regarded as perhaps the most promising in the field of trauma. Since the publication of the first edition of this book in 2010, EFTT has been recognized as among a handful of empirically supported effective treatments for complex traumatic stress disorders. The EFTT treatment model described in this book has been developed through detailed process and outcome research supporting not only efficacy but also in-session processes of change. Each intervention discussed in this book simultaneously has been informed by practice with hundreds of clients and the training of professionals across the world. This tradition of emotion-focused therapy theory, research, practice, and training, to which we have added, affords clinicians a high degree of confidence in the treatment model. The EFTT treatment model (relational and intervention components) also has promising applications to diverse types of complex and cumulative relational trauma that are increasingly prominent in the literature. Practitioners, including us, have been applying aspects of EFTT to, for example, refugee trauma, human trafficking, domestic violence, combat trauma, and transgender populations. Therapists have also begun to explore adjuncts to EFTT, such as psychedelics, and the integration of body-based interventions drawn from yoga therapy (see Appendix D, this volume). We hope that future research and practice will continue to explore and develop these new directions.

THE IMPACT ON THERAPISTS OF DEEP EMOTIONAL ENGAGEMENT WITH TRAUMA Anyone who works with trauma is frequently appalled and saddened and sometimes disturbed by the cruelty, pain, and suffering people can inflict on one another, particularly children. Questions are frequently asked in our training sessions about the impact on therapists working with clients at the deep level of emotional engagement characteristic of EFTT. These concerns are expressed by both novice therapists and more senior practitioners who are interested in focusing more on trauma or working on a deeper emotional

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level. The issue of vicarious traumatization among health care practitioners has been a focus of discussion and research for many years (Harrison & Westwood, 2009; Pearlman et al., 2020). EFTT therapists, regardless of the client’s presenting problem, need to be comfortable with intensely painful emotion—their own and their clients’. This is especially true in the field of complex trauma. We have both had the experience of watching our children and grandchildren playing, completely innocent and carefree, and suddenly remembering the story of one of our clients and being sickened by the thought of our kids being hurt this way. Experiences like this are common among trauma therapists; they are disturbing and can be difficult to shake. It can be important for therapists to process these experiences with their own therapist or supportive colleagues. Nonetheless, the potential for deep emotional connection with our clients is precisely the power of emotion-focused treatments such as EFTT. Complex trauma, at its core, involves a constellation of disruptions to the emotion system, and effective treatment requires more than simple fear inhibition. In our experience, the empathic and compassionate relationship quality of EFTT permits a deep connection to humanity that is nourishing and profoundly rewarding for therapists as well as clients. EFTT also provides a rich repertoire of tools (process maps and specific interventions) for working with the full range of emotions and emotional processing difficulties characteristic of complex traumatic stress disorders. We have found the process of client emotional transformation that occurs in EFTT to be a highly creative coconstructive process that also enhances therapists’ personal and spiritual growth. We hope that this book will inspire and empower clinicians to learn and practice this powerfully enriching clinical approach.

APPENDIX A

Short Form of the Client Experiencing Scale Level 1 2 3

4 5 6 7

Content

Treatment

External events; refusal to participate External events; behavioral or intellectual descriptions of self Personal reactions to external events; limited descriptions of self; behavioral descriptions of feelings Descriptions of feelings and personal experiences Problems or propositions about feelings and personal experiences A “felt sense” of an inner referent

Impersonal, detached Interested, personal, participation in the process Reactive, emotionally involved

A series of “felt senses” connecting the content

Self-descriptive, associative Exploratory, elaborative, hypothetical Focused on there being more about “it” (the topic) Evolving, emergent

Note. Adapted from The Experiencing Scale: A Research and Training Manual, Vol. 1, by M. H. Klein, P. L. Mathieu, E. T. Gendlin, and D. J. Kiesler, 1969, University of Wisconsin Extension Bureau of Audiovisual Instruction. Copyright 1970 by The Regents of the University of Wisconsin. Adapted with permission.

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APPENDIX B

Short Form of the Working Alliance Inventory Scale: 1 = never, 2 = rarely, 3 = occasionally, 4 = sometimes, 5 = often, 6 = very often, 7 = always Questions: 1. My therapist and I agree about the things I need to do in therapy to help improve my situation.   2. What I am doing in therapy gives me new ways of looking at my problems. 3. I believe my therapist likes me. 4. My therapist does not understand what I am trying to accomplish in therapy. 5. I am confident in my therapist’s ability to help me. 6. My therapist and I are working toward mutually agreed-upon goals. 7. I feel that my therapist appreciates me. 8. We agree on what is important for me to work on. 9. My therapist and I trust each other. 10. My therapist and I have different ideas of what my problems are. 11. We have established a good understanding of the kinds of changes that would be good for me. 12. I believe the way we are working with my problems is correct. Note. Adapted from “Development and Validation of the Working Alliance Inventory,” by A. O. Horvath and L. S. Greenberg, 1989, Journal of Counseling Psychology, 36(6), p. 266 (https://doi.org/10.1037/ 0022-0167.36.2.223). Copyright 1989 by the American Psychological Association.

 301

APPENDIX C

The Degree of Resolution Scale (Short Form) The following scale describes hierarchically organized processes as clients move closer toward the resolution of past issues with an identified other. 1. The client expresses lingering bad feelings, hurt, blame, complaint in relation to a significant other. The client may feel resigned or suppresses associated feelings. 2. An emotional reaction is evoked in making psychological contact with the imagined other. The client expresses hurt, bitterness, fear, or hopelessness about ever resolving the bad feelings. 3. Bad feelings toward the other are differentiated into clear expression of anger or sadness with associated meanings and a high degree of emotional arousal. 4. The client feels entitled to unmet needs which are experienced as valid and legitimate. 5. The client is more separate from the other, no longer seeking retribution or to satisfy unmet needs. The client has a more differentiated perspective of the other as a more “life-sized” person with problems of their own. 6. The client affirms the self, lets go of expectations that the other will apologize or change, may forgive the other and/or holds the other accountable for harm.

Note. Adapted from Facilitating Emotional Change: The Moment-by-Moment Process (p. 249), by L. S. Greenberg, L. N. Rice, and R. Elliott, 1993, Guilford Press. Copyright 1993 by Guilford Press. Adapted with permission.  303

APPENDIX D

Yoga Therapy as a Complement to EFTT Integrating Body-Based Interventions Sandra C. Paivio, Katlin J. P. Robinson, and Antonio Pascual-Leone

This appendix is an addendum to the book and stands as an independent contribution, one that fills a special need when considering the treatment options for working with complex trauma. Complementary care using a body-based approach can be a valuable support for the ongoing treatment of mental health issues, particularly as they relate to complex trauma. While this appendix to the book is not necessary for practicing standard emotion-focused therapy for trauma (EFTT), our purpose is to illustrate how the therapist might further enrich EFTT by also engaging in body-based intervention. The integration of yoga-based interventions into EFTT practice is an example of body-based work that can help shore up certain client processes where traditional talk therapy may be lacking. Furthermore, while yoga is on the frontier of inquiry in developing treatments for mental health issues, there is a significant lack of concrete instruction on how therapists might functionally integrate such approaches. This appendix helps fill that gap, at least as it specifically applies to EFTT.

Katlin Robinson is a yoga therapist certified by the Canadian–International Association of Yoga Therapists. She is certified as an Experienced Registered Yoga Teacher, having completed 500 hours of yoga teacher training (ERYT200/RYT500). She is located in London, Ontario, Canada, and specializes in yoga for mental health and women’s wellness. She has been practicing yoga and mindfulness techniques for almost 20 years. Katlin works with clients through workshops, group classes, and one-on-one yoga therapy. She also offers advanced training and mentorships for yoga teachers (RYT300 and CE), body and movement for therapists and mental health professionals interested in using yoga practices, and philosophy to support their clients’ mental health. Her focus is on teaching the richer inner teachings and traditions of yoga that reduce stress, enrich people’s lives, and promote healing at the deepest level of the self. https://www. katlinrobinson.com  305

306  Appendix D

The goal of this appendix is first to spark interest in exploring how bodybased intervention derived from yoga therapy can be integrated into EFTT. The second goal is to specify criteria for integrating yoga therapy practices with sufficient detail so that readers can begin to explore their use in clinical practice. The overarching objective is to expand the benefits of EFTT to an even wider range of clients and client processing difficulties. Many therapists (and clients) reading this book will be familiar with traditional yoga practices, and there is no shortage of resources available for readers who wish to learn basic yoga techniques. However, specialized training in yoga per se is not a requirement for implementing interventions in this appendix. For therapists who are sensitive to body language and familiar with body-based practices, including yoga, the integration of body-based intervention and talk therapy will intuitively make sense. Interventions described here are based on familiar and well-accepted constructs in the psychotherapy literature and can be readily integrated into EFTT sessions. For example, all psychotherapeutic approaches, including EFTT, recognize the relationship between breath and emotion regulation; the connection between the body and emotion; the power of visualization and imagery to evoke internal experience; the role of intentions, needs, and desires in motivating behavior; and the value of mindfulness in cultivating present-centered awareness. Our book has described the basic EFTT model in 12 chapters, and this appendix contributes to that. We describe ongoing explorations on integrating body-based practices drawn from yoga therapy to augment EFTT interventions and maximize client change. Change in EFTT is contingent on clients’ awareness of emotion, ability to regulate and reflect on emotional experience, and access to healthy capacities to counteract maladaptive emotion schemes to change the “same old story”—this is the essence of emotional transformation. Yet anyone learning and practicing EFTT will come across clients for whom standard EFTT interventions described in the preceding chapters fall short. The following sections describe these entrenched client processing difficulties and how yoga-based practices might help as an adjunct to EFTT.

EMOTION DYSREGULATION Empathic responding is the primary EFTT intervention used to reduce client distress. In cases of severe emotion dysregulation, EFTT draws on well-known techniques, such as physical grounding, breathing, or mindfulness used in other approaches to trauma therapy (e.g., Linehan, 2015). For many clients, these emotion regulation techniques can be employed in session as markers of dysregulation occur. However, some clients do not respond to the introduction of these interventions in the moment-to-moment process. As noted in the earlier chapters of this book, clients who engage in self-harm behaviors to cope with high levels of emotional pain and distress, for example, frequently need to learn and practice emotion regulation strategies in session and between sessions before in-depth trauma exploration is safe. For other clients, techniques such as

Appendix D  307

mindfulness that involve attention to internal experience can be trigger­ing or too agitating to be effective as a regulation strategy in the moment. Moreover, high levels of chronic anxiety, both outside of therapy and in session, interfere with clients’ ability to participate in EFTT interventions, including two-chair dialogues aimed at exploring and reducing anxiety. Yoga therapy offers a variety of calming techniques as well as activation strategies that can counter emotional numbness and depression.

POOR AWARENESS OF EMOTIONAL EXPERIENCE Emotion-focused therapy emotion awareness interventions include empathic responding and conjecture, as well as the explicit emotion coaching described throughout this text. Research indicating reduced alexithymia (from 80% to 20%) pre- to post-EFTT support the effectiveness of these standard interventions (Paivio et al., 2010). However, 20% of clients in the Paivio et al. (2010) study continued to meet the criteria for alexithymia at the end of therapy. Other clients have limited access to specific emotions—anger versus vulnerability or vice versa. Yoga therapy body-based interventions that facilitate specific internal states (e.g., empowerment or letting go) can contribute to the awareness of internal experience, in general, and awareness of specific emotional experiences. A related deficit is poor awareness of bodily experience. EFTT interventions, such as experiential focusing, use bodily awareness as an entry point to emotion awareness and thus to deepening experiencing (see Chapter 5, this volume). However, some clients have learned to shut down or ignore bodily experience due to trauma, illness, or comorbid disorders such as anorexia or panic. Their bodies may be a source of betrayal, disgust, or fear. Yoga therapy strategies explicitly focus on increasing awareness of bodily experience and have a rich repertoire of language for describing bodily experience.

DIFFICULTIES WITH EXPERIENCING (EXPLORING EMOTIONAL MEANING) Many clients can identify and label feelings and provide accounts of events that are personally meaningful, but these are overly rational and intellectual, not experientially grounded. In session, they may be minimally responsive to empathic responses, questions, or directives aimed at helping them focus on and explore affective experience, or they continually deflect from such a focus. Yoga therapy interventions help clients identify and experience the physical discomfort (e.g., tension, heaviness, weakness) of problematic emotions, thoughts, beliefs about the self and others and, conversely, the sense of comfort (e.g., balance, strength, lightness, openness) of healthy experience, including values and heartfelt desires. These embodied resources are then available for meaning exploration and can motivate adaptive action.

308  Appendix D

DIFFICULTIES WITH EMOTIONAL TRANSFORMATION Change in EFTT, regardless of the procedure, is contingent on clients accessing internal positive and self-protective resources (i.e., adaptive emotion and associated core needs, desires, beliefs, behaviors) to modify the maladaptive emotion scheme. However, some clients are unable to access these positive experiences and, therefore, are unable to resolve interpersonal and self-related issues. Healthy protests about maltreatment, self-empowerment, or compassion do not spontaneously emerge, nor do therapists’ attempts at coaching or suggesting such positive experiences seem to bring about sustained change. There is no shift; they are “stuck” in the same old maladaptive pattern, which can go on for weeks. Yoga therapy has a large repertoire of interventions that foster positive experience. The following section describes the features of yoga therapy that are relevant to and compatible with EFTT.

WHAT IS YOGA THERAPY? Yoga therapy is an emerging discipline applied to the treatment of physical and psychological disorders, including trauma and anxiety. Yoga therapy, as distinct from yoga classes, is not exercise or “stretching” but a multidimensional approach to healing that can be used as an adjunctive treatment to talk therapy (Emerson et al., 2009; Gerber et al., 2018). A Holistic Approach Yoga therapy’s multidimensional approach includes body and breath awareness, meditation, values and standards, and existential and spiritual meaning. In traditional yoga, the integrated practice of all these dimensions is thought to reduce suffering and increase the capacity for positive ways of being—a sense of wholeness, happiness, peace, and serenity (Devi, 2007). Many of these principles and practices overlap with contemporary Buddhist practices that are prominent in popular Western culture and current psychotherapeutic approaches (e.g., dialectical behavior therapy—Linehan, 2015; acceptance and commitment therapy—Hayes et al., 2012; cognitive therapy for depression— Segal et al., 2013), including emotion-focused therapy (Gayner, 2019). Body-Based Practices The most familiar aspects of yoga in Western culture are asanas or postures and breathing practices. In traditional yoga practice and yoga therapy, there are many sophisticated techniques for “sculpting” the breath to produce different effects (calm, energy, balance), and these techniques can be incorporated into postures and meditation. In current yoga therapy, traditional postures are modified as needed to meet individual client limitations and needs, or idiosyncratic postures, gestures, and movements can be collaboratively developed.

Appendix D  309

Again, these are not used as “exercises” but to promote present-centered body awareness, in general, and awareness of specific psychological and emotional states (e.g., openness and vulnerability, strength and empowerment, stability and balance, calm, energy, vitality). From a yogic perspective, the body is not only a correlate of psychological experience but also an entry point to these other dimensions of being (i.e., thoughts, feelings, desires) that can be deliberately used to induce positive states and help counteract negative ones. Meditation Yoga therapy also includes a variety of meditation practices, all of which are grounded in the body and breath. It is thought that all yoga body-based practices are themselves forms of meditation designed to enhance nonjudgmental observation, awareness, and acceptance of present embodied reality. Guided meditation can be practiced lying down or sitting or can involve movement (e.g., walking); the use of sound, music, inspiring text, or imagery; and basic mindfulness observation. Yoga therapy meditations also frequently focus on the embodied experience of heartfelt intentions for living (see the following section), as well as existential and spiritual meaning and values. Values and Standards Traditional yoga philosophy includes values and standards for personal and social behavior (yamas and niyamas; Adele, 2009). These principles are consistent with humanistic values and Buddhist philosophy (e.g., self-awareness, compassion or loving-kindness, acceptance of present reality) that have been integrated into Western culture and psychological practice. Yoga therapy draws on these principles to help clients identify and deeply experience what is most important to them, their core existential values and concerns, and their heartfelt intentions (sankalpa) for how they want to treat themselves and others. These are consistent with EFTT core values, concerns, and intentions implied in adaptive emotional experience. Existential and Spiritual Meaning Although many contemporary Western approaches to yoga are purely secular, the highest branch of traditional yoga is the spiritual level of development (Devi, 2007). Yogic spiritual principles include wholeness, balance and harmony of opposites, cycles of change, the interconnectedness of all things, and the preciousness of life. Through the ages, spiritual beliefs and practices have helped people find peace in the middle of life’s troubles and experience more enduring states of happiness, harmony, and serenity beyond moods or emotional states. From a secular perspective, promoting this dimension of wellbeing involves a regular connection with experiences of wonder and awe (e.g., nature, art, poetry, music, science, being with children). For many, the appeal of yoga is its promise of deeper levels of happiness and serenity beyond

310  Appendix D

that provided by materialistic values. Again, yoga therapy practices help clients deeply experience these positive states, taste them, know that these experiences are possible, and increase their agency in cultivating them and incorporating them more regularly into their lives.

BACKGROUND LITERATURE ON YOGA THERAPY Body-based interventions for trauma are supported by considerable recog­ nition of the neurobiological effects of trauma—release of stress hormones, muscle constriction, and dysregulation of the nervous system—that influence psychological areas of functioning (Ford, 2020; van der Kolk, 2014). From a neurobiological perspective, chronic and repeated exposure to trauma involves constant nervous system dysregulation, which the organism seeks to balance or regulate. From a psychological perspective, this involves self-protective distancing responses that work in the short term but keep the individual in a constant state of imbalance, cycling between hyperarousal and shutting down, leading to exhaustion. According to polyvagal theory (Porges & Dana, 2018), with every exposure to trauma and unresolved reactivation of traumatic fear, the “window of tolerance” for emotional arousal shrinks, so the person becomes less resilient to triggers of threat. The fear response is more easily activated, and the same neurobiological reactions, feelings, beliefs, and defensive behaviors are activated. From an emotion-focused therapy perspective, this is the “same old story” embedded in the maladaptive emotion scheme that people seek to change in therapy. These effects can be reduced as a by-product of psychological treatment and the emotional processing of trauma. However, sometimes (e.g., when the client is overwhelmed by trauma feelings and memories) nervous system dysregulation needs to be directly targeted by a body-based intervention such as breathing and relaxation. Over time, clients learn to gain control over their nervous system dysregulation. The Goal of Yoga-Based Intervention Emerging from the theory of dysfunction, the general goal of yoga therapy for trauma is to regulate the nervous system—grow the window of tolerance so the person is not as reactive to triggers, thus increasing resiliency and the potential for harmony and balance (equanimity). The practices employed by yoga therapy (described in later sections) are designed to increase balance or harmony and client agency in producing these positive experiences. These new positive bodily experiences influence psychological and emotional dimensions of awareness and are integrated into everyday life. Effectiveness of Yoga and Body-Based Approaches There is abundant recognition of the mind–body connection in psychological practice. Popular programs, such as mindfulness-based stress reduction

Appendix D  311

(Kabat-Zinn, 1990, 2003), combine breath work, meditation, and yoga practices to promote psychological well-being. Yoga programs also have been developed to address symptoms of anxiety (downregulating) and depression (upregulating; e.g., Weintraub, 2003). Although research on yoga is in its infancy, there is evidence supporting the effectiveness of these programs as adjuncts to psychological treatment (e.g., Capon et al., 2021; Simon et al., 2021). Trauma-sensitive yoga programs (Emerson & Hopper, 2011; Smith & Ford, 2020) have also been developed that modify traditional yoga classes to meet the needs of trauma survivors. Research supports the efficacy of these approaches—for example, for women survivors of domestic violence (Clark et al., 2014), women with histories of interpersonal trauma (van der Kolk et al., 2014), and male military veterans (Reinhardt et al., 2018). Studies also support the effectiveness of integrated restorative yoga nidra (Miller, 2015), a form of meditation described later, as an adjunct alternative treatment for reducing posttraumatic stress disorder (PTSD) in veterans.

PROCESSES AND GOALS OF YOGA THERAPY WITHIN EFTT Several features of yoga therapy make it compatible with EFTT, as described in the preceding chapters. First, yoga therapy is a collaborative one-on-one process rather than teacher directed. Interventions involve open dialogue, the therapist checking in with the client throughout the practice to monitor the effects of the practices and adjusting and modifying as needed. Second, all practices are adapted to the individual rather than prescriptive. The client is the expert in their experience, and there are no “correct” practices. In all practices, clients are provided with options and choices to suit their physical limitations, preferences, and needs. Importantly, yoga therapy promotes an atmosphere of curiosity, playfulness, and exploration. The goals of yoga therapy specifically tailored to EFTT are to augment standard EFTT interventions aimed at addressing client emotional processing difficulties related to awareness, regulation, reflection on emotional meaning, and transformation (access to positive experience). These goals are described in the following subsections. Increase Awareness of Internal Experience Almost by definition, all yoga therapy interventions are intended to increase individuals’ awareness of internal experience (both positive and negative), beginning with bodily experience. Similarly, in EFTT, body awareness can be an entry point for emotional awareness and deepening emotional experiencing (see Chapter 5). In both yoga therapy and EFTT, postures that promote specific experiences (described later) are used as tools both to assess client capacities and comfort with desired internal states (e.g., empowerment) and to evoke and deepen feelings (e.g., assertive anger). Yoga therapy offers techniques for increasing poor awareness of bodily experience—for example,

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beginning with a gentle shaking of hands and feet, movements, and awareness of associated sensations (e.g., warmth, tingling). This can gradually expand to awareness of associated emotional experience and meaning. Downregulate Emotional Arousal Yoga therapy interventions (e.g., breathing techniques, postures, visualizations) that promote emotion regulation and expand the window of tolerance (Porges & Dana, 2018) can support trauma exploration in any therapy. In EFTT, adequate emotion regulation is also necessary for client exploration of emotional meaning and productive engagement in EFTT procedures. Arousal must be sufficiently high to activate emotion schemes and then moderated to allow exploration of meaning. Establish Intentions Yoga therapy intervention helps clients establish their sankalpa (translated from Sanskrit as “timeless truth”), or heartfelt intentions, aspirations, and desires—for a session, the day, therapy, or their life—and deeply experience the imagined manifestation of these in their life. This sankalpa complements the basic emotion-focused therapy intervention principle of establishing intentions (see Chapter 3), which aims at mobilizing clients’ wants, needs, desires, values, concerns, and action tendencies associated with emotional experience. As noted throughout this text, these are the basis for therapeutic goals and adaptive internal resources used to change maladaptive emotion schemes and motivate change. Intentions are also related to client core values and concerns that can be an entry point to deepening low-level experiencing (see Chapter 5) and promote the exploration of emotional meaning. Shift Out of Negative States Yoga therapy interventions within EFTT can support clients’ shift out of maladaptive emotions of shame, fear, and overcontrol of experience. This supports the change processes in emotion-focused therapy two-chair dialogues, for example. Yoga-based interventions can increase awareness of and help clients deeply experience the physical discomfort of “hurting” oneself emotionally—for example, constriction, tension, shallow breath, shrinking away—and activate an opposite desire to feel more comfortable. Enhance Positive Experience A hallmark of yoga and yoga therapy is that interventions are designed to enhance positive internal experience (Devi, 2007; Emerson et al., 2009). Postures and gestures can increase awareness of the strength and sense of selfempowerment associated with anger and the relief and release of surrendering to sadness and grief or letting go of “tight-fisted” overcontrol, for example.

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This embodied awareness concretizes and enhances previously subdominant adaptive experience in EFTT to help consolidate change. An important subgoal in this process is to increase client agency in producing both positive and negative feeling states. Thus, yoga therapy interventions support the process of emotional transformation in emotion-focused therapy, described throughout this volume. The following subsections focus on the types of positive experiences yoga therapy interventions are designed to promote. Positive Experiences Yoga Therapy Is Designed to Promote Yoga therapy, specifically as used in EFTT, focuses on promoting five basic groups of positive experience: grounding or calmness, safety, empowerment or agency, compassion or kindness, surrender or letting go. These groups are described as follows. Grounding or Calming to Promote Presence Grounding techniques help the client feel focused, centered, balanced, and present. Calming is a prerequisite, but grounding is distinct from relaxation. Grounding is essential to the introspection and reflection (experiencing) that is central to emotion-focused therapy. Grounding in the present reality of the body and breath counters dissociation, feelings of agitation, and mental hyperactivity (clients who “live in their heads”). Yoga therapy includes a variety of grounding strategies (e.g., simple breathing, postures, gestures, movements, imagery) and standard physical grounding techniques, such as focusing on sensation or external stimuli. Safety to Counter Fear The defining feature of trauma exposure is fear and the need for protection and safety. Provision of safety is the first step toward increased self-empowerment. Yoga therapy includes postures or gestures intended to help clients feel safe, strong, and protected. These can be used to help them approach painful, threatening material in session. This physical self-soothing of fear can be accompanied by verbal self-soothing (e.g., “You are here, now, safe”) used in EFTT and other trauma therapies. Empowerment or Agency to Counter Powerlessness The goal of interventions to promote empowerment is to help the client feel strong and confident and counter the helplessness and powerlessness associated with traumatic victimization. Empowerment is a requirement for safety, allowing vulnerable feelings, adaptive anger expression when confronting imagined others, expressing entitlement to unmet needs, and asserting healthy interpersonal boundaries, all of which are essential to healing in EFTT. Yoga therapy interventions complement EFTT body-based interventions used to promote assertiveness (e.g., encouraging clients to sit up straight, with their feet on the floor as they confront imagined perpetrators).

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Compassion and Kindness to Counter Self-Criticism or Angry Rejection The goal of compassion-based interventions is to foster kindness toward the self and others. Gentle and caring behavior toward the self can counter painful shame-based feelings generated by self-criticism or anxious perfectionism. Compassion for others can counter rejecting anger and be a part of interpersonal resolution—accepting the other as a flawed, suffering human being and offering pity or forgiveness. Yoga therapy interventions to counter maladaptive shame and rejecting anger complement the EFTT interventions described in Chapter 10 of this volume by directing attention to the physical pain of these maladaptive experiences. This can activate healthy needs for gentleness and comfort to reduce pain. Surrender or Letting Go to Counter Overcontrol The goal of surrender is to let go of the chronic hypervigilance and overcontrol developed through repeated exposure to unpredictability and potential threat. These emotional states are accompanied by chronic physical tension. The first step in letting go of overcontrol is increased safety and empowerment, as described earlier. In EFTT, surrender is essential to allowing emotional pain and grieving loss. Surrender and letting go of unrealistic expectations are essential to the acceptance of the self and others. Yoga therapy interventions can help clients be aware of the physical discomfort and exhaustion of chronic tight-fisted overcontrol, and “releasing” postures are used to counteract these negative experiences. In addition to these goals, sometimes, yoga-based interventions can increase clients’ sense of vitality to counter the numbness or shutting down of depression (Weintraub, 2003) that is frequently comorbid with complex PTSD. Interventions focused on the breath and simple movements (e.g., shaking hands and feet, “windmill arms”) increase blood flow, oxygen intake, and awareness of basic sensations (e.g., tingling, warmth) to help clients feel more alive.

INTERVENTION PRINCIPLES Intervention principles in both EFTT and yoga therapy are therapist intentions that can be realized through several specific tools or techniques. Understanding the underlying principle enables the therapist to appropriately, flexibly, and seamlessly adopt specific tools tailored to individual clients. Several fundamental intervention principles are common to both EFTT (see Chapter 2) and yoga therapy, except that yoga therapy is more specifically focused on the body and the breath and, when appropriate, the connection of these dimensions to emotion. These intervention principles include present-centered awareness, nonjudgmental observing and acceptance of internal experience, validating experience, accurate labeling of bodily experience, and symbolizing internal experience. Yoga therapy uses not only verbal symbols (words and metaphors) but also visual images and sounds to describe

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and capture the essence of an embodied experience. This is analogous to identifying a “handle” in the focusing procedure (Chapter 5). Other fundamental intervention principles compatible with EFTT include establishing intentions, promoting agency (described in earlier sections), and making successive approximations to the desired experience, beginning with the client’s comfort zone. This was discussed in Chapter 9 (this volume) on anger. Although yoga therapy is not an exercise program, many clients participate in various forms of exercise, including yoga, and yoga therapy intervention begins with what they are familiar and comfortable with. For example, clients may be familiar with “stretching” postures to reduce physical tension. They can be encouraged to focus, instead, on the experience of release, “letting go,” and “surrendering” (to gravity, to “Mother Earth”) to counteract the chronic overcontrol that generates tension. Finally, an important yoga therapy intervention principle is to practice with clients. The therapist does not instruct, demonstrate, and observe the client at a distance, as in a yoga class, but engages in practices alongside the client. This reduces client performance anxiety and aloneness. From a neurobiological perspective, this mirroring and interpersonal connection also promote emotion regulation (Porges & Dana, 2018). The following section describes specific body-based practices and tools that can be integrated into EFTT and provides examples of each. Detailed descriptions and instructions for standard yoga postures and breathing practices are beyond the scope of this chapter. We provide general guidelines for these and refer the reader to the abundant written and online material that can provide detailed illustrations and guidelines for specific standard yoga practices (e.g., Emerson & Hopper, 2011; Le Page & Le Page, 2013; Robinson, 2021).

PRACTICES AND TOOLS The following practices and tools can be easily assimilated into EFTT sessions, either in the moment-by-moment process at appropriate markers or the beginning or end of sessions to help produce desired psychological states. Subsections are organized according to the major domains of practice identified earlier in the chapter. Attention to the Breath Breath work facilitates emotion regulation. Yoga therapy offers dozens of ways of sculpting the breath for different effects. For our purposes, there are three basic categories of breath practice: downregulating to produce calm and grounding, upregulating to increase energy and vitality, and balancing to increase focus and equanimity (evenness of mind, composure). These breathing practices are used in conjunction with postures, movement, imagery, and meditation practices described in later sections.

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Standard breathing techniques to induce relaxation and calming responses typically involve belly breathing and lengthening the exhale (Linehan, 2015; Najavits, 2002). In yoga therapy, clients also are encouraged to place a hand on the belly or one hand on the belly and the other on the heart area and attend to the rise and fall of the body. The placement of the hands facilitates proper breathing by directing attention to the appropriate area and can also provide a sense of comfort and warmth. However, bellows breath (fast paced, forced inhale and exhale) is designed to increase oxygen intake and heart rate and can help clients who are feeling depressed and numb to experience increased energy and vitality (Weintraub, 2003). Lion’s breath (think a lion’s roar or Maori warrior) involves a forced exhale, with eyes and mouth wide open and tongue out, and can increase a sense of empowerment. Circular breathing is used to increase a sense of balance and equanimity. This entails an equal count of four or five with each inhale and exhale, with a hand on the belly, feeling it rise and fall, perhaps gradually increasing the count and noticing the pause at the top of the inhale. Attention to the Body Yoga therapy body practices include postures or asanas, hand postures or mudras, gestures, and movements. As noted throughout this text, attention to bodily experience is intrinsic to EFTT: clenching the fist in anger, stroking the leg for soothing, folding the arms across the chest or turning the back on the imagined other for “walling off,” or extending the hand and arm in a stop or “back off” gesture for assertive boundary definition. These gestures are used to activate and increase awareness of specific emotional experiences, facilitate productive emotional expression, and deepen experiencing. Yoga therapy interventions can augment and enhance these EFTT interventions. Yoga is best known for its full body postures or asanas and for movement— slow and rhythmic to calm and vigorous to increase energy and vitality. Yoga also includes a wide repertoire of hand postures or mudras (Le Page & Le Page, 2013; Robinson, 2021) that can be used alone or in conjunction with body poses and breathing practices. Commonly used examples are “prayer hands” for honoring or greeting or “hand on heart” for compassion. Numerous less well-known examples can have subtle, evocative, and aesthetically pleasing effects. Mudras can also easily be integrated into the moment-by-moment process of therapy and unobtrusively used by clients anywhere and at any time—sitting on the subway, standing in line at the grocery store, or walking down the street. The hands are neurologically highly sensitive and connected to other parts of the body and are highly expressive. Clients can be taught the standard yoga intention behind each mudra and use them as a symbol to cue what they are trying to cultivate (e.g., grounding, empowerment, compassion). Alternately, clients can be asked to attend to and articulate their experience of traditional mudras.

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General Guidelines for Body-Based Practices Because language frequently reflects embodied emotional experience (e.g., the weight of the world on your shoulders), the effects of many postures are often intuitively obvious. However, when suggesting a specific posture or movement, therapists need to be clear on their intentions, which is determined by specific client internal processing difficulties and needs. It also is important to differentiate among similar but distinct experiences and needs to determine the appropriate intervention. For example, different interventions are used to promote related but distinct experience: calmness (regulation), grounding (present centeredness), balance (equanimity, composure), stillness (internal focus), or self-soothing (kindness or comfort). This is consistent with emotion-focused therapy’s highly differentiated perspective on emotional experience. In general, focusing downward (bum on a chair or feet on the floor) promotes grounding and presence, standing or sitting erect (straight spine, strong legs) promotes strength and empowerment, closed postures (limbs pulled in, arms curled around the body, fingers curled in) promote protection and safety, and open postures (arms open, heart exposed and vulnerable) promote trust and welcoming. The direction of the gaze can complement postures: straight ahead for firmness and stability; down for protection, grounding, or turning in; and up for uplifting. In all instances, interventions help clients describe the sensations associated with specific postures and gestures and generate a verbal or nonverbal (e.g., image, sound) symbol for their bodily experience. Clients are also encouraged to experiment with different postures to explicitly experience and increase awareness of their embodied effects. Intervention validates and helps increase clients’ awareness of any discomfort they may experience with postures and encourages them to modify postures to suit their needs—for example, the difference between arms open and closed, palms up or resting on the lap, and the gaze looking up or down or straight ahead. The following subsections provide suggestions for body-based interventions intended to cultivate specific positive experiences. Grounding and Calming The most basic yoga posture for promoting grounding and presence is “mountain pose.” This involves simple, relaxed standing with legs straight down from the hips, attention to feet on the floor, rooted like a tree, strong and flexible. Clients can be asked to imagine their favorite trees or notice the effects of different arm positions and gaze and see which they prefer. Hand postures can enhance this experience of grounding, such as bhu mudra—index and middle fingers pointing toward the floor and the thumb over the other curled fingers, imagining the fingers as “grounding wires.” The accompanying intention is “I am exactly where I need to be,” or “I am connected to the earth’s wisdom.” This also can be practiced sitting. A client who practiced mindfulness as an emotion regulation strategy liked this mudra and, after a few weeks of including it

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in his practice, found that it quickly cued a feeling of grounding and presence. Another hand posture that can help cultivate grounding and stillness is adhi mudra—thumb tucked into fist (like a “baby in utero”) with hands effortlessly resting on the lap. The accompanying intention is “coming home to the self.” This mudra, along with slow belly breathing, can help clients shift from an external to an internal focus of attention (“tucking in”)—for example, before the focusing procedure. Movement also can promote grounding. Gentle or vigorous shaking of hands and feet, then attending to and describing the sensation (e.g., warmth, tingling) in the extremities increases awareness of bodily experience and helps clients get out of their heads—attention is literally farther away from the head. When clients are highly restless and agitated, movements such as shaking arms and legs or “sufi grind” (circling the upper body while seated) can help to shake off or “grind out” nervous energy before they can settle into stillness. An example of subtle movement to facilitate grounding is touching the thumb to each fingertip starting with the forefinger, then the reverse, using both hands, then each hand in the opposite direction, slowly and mindfully, ideally in sync with the breath. One client found this a distraction from emotional pain when she was triggered (e.g., on the subway), as well as rhythmic and soothing. For clients who seek balance, merudanda mudra is the popular “two thumbs up” gesture practiced with elbows bent at 90  degrees and tucked into the sides. When practiced in a grounded standing posture, this obviously balances the right and left sides of the body and can be extrapolated to internal experience more generally—balancing the head (reason, logic) and heart (emotion, experience). Clients can playfully use this mudra in conjunction with its popular meaning to indicate two thumbs up or “praise” for balance. Safety The basic yoga posture for protection and safety is “child’s pose”—curled up on the floor, face down, with knees drawn to chest, fully “supported by Mother Earth.” However, this is not physically accessible to everyone. Alternatives are curling up on a couch or chair, hugging knees to chest, or hugging a pillow, gazing downward. This can be accompanied by gentle rocking. A simple hand posture that is thought to cultivate security and trust is chinmaya mudra—gently touching the thumb and index finger, like pincers, with other fingers tucked in. Although not all clients will experience the intended effect of increasing a sense of security, holding this posture with hands resting in the lap, palms down, can lengthen the exhale and help release tension in the shoulders and upper back. This reduced physiological tension can contribute to an increased sense of safety. Empowerment Feelings of helplessness and physical paralysis are endemic to traumatic victimization. Body-based interventions for clients who struggle with powerlessness invite them to experiment with standing power postures and attend to their experience of firmness, stability, and strength, “taking a stand,” and

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“standing your ground.” There are many standard yoga power poses (e.g., warrior, goddess) that require stability and strength in the legs. A playful alternative is the “superhero” stance, with legs slightly apart and arms folded across the chest or hands on the hips. One client adopted the “Wonder Woman” stance with arms crossed over her heart and fists clenched when she confronted her imagined father in imaginal confrontation (IC). A particularly evocative hand posture for empowerment is the Garuda mudra—the name of the mythic Hindu eagle that symbolizes courage. This resembles the familiar posture of resting the hands on the heart, one on top of the other, for compassion (described in the next subsection), except in Garuda, the fingers are gently extended, and the thumbs curled around each other for protection, stability, strength, and determined focus. One client who was taught this mudra at the end of an intensely painful session became tearful. The therapist validated her experience, “Yes, it’s lovely, isn’t it? I can see this is very meaningful to you.” The client responded, “For me, it’s courage to face my fears. And I’m going to teach this to my daughter.” Another client used it whenever she remembered herself as a young girl cowering in fear of her mother’s rage. Compassion In general, postures and gestures that promote self-compassion and nurturing are slow, gentle, and comfortable. A simple but evocative posture that enhances tenderness and self-soothing involves resting the hands on the face while breathing gently and directing attention to the feeling of warmth and comfort. A familiar hand posture that symbolizes compassion and kindness is the hridaya mudra—hands on top of each other on the heart. The accompanying yogic intention is “I trust the wisdom of the heart.” Kapota mudra (white dove)—hands gently cupped as if holding a butterfly—is an aesthetically pleasing alternative to the classic yoga prayer hands used to symbolize selfcare and healing. Asanas for kindness and compassion toward others generally involve open chest and arms in a gesture of open-heartedness and welcoming. Clients can open their arms wide, slowly bring their hands together into prayer pose (or rest on their heart), and imagine gathering the other, the world, into their hearts. Arms and hands extended with palms up can enhance the experience of openness, generosity, and offering or the experience of receiving, depending on the intention. All these mudras and gestures can easily be integrated into the moment-by-moment process of EFTT to support and deepen clients’ healthy strivings for compassion toward the self and others. Surrendering or Letting Go The classic yoga posture of surrender and letting go is savasana (relaxing pose)—lying flat on the back with legs and arms extended slightly away from the body, chest open and exposed. This simple posture can be extremely difficult for clients who are feeling vulnerable and who are chronically anxious, tense, and overcontrolled. Yoga therapy interventions to promote the experience

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of surrender and letting go include releasing postures such as standing forward fold—bending at the hips (or elbows resting on bent knees), dangling like a rag doll, spine long, feeling the weight of the head and upper body releasing more with each exhale. In EFTT, this is accompanied by the therapist’s verbal encouragement to “Let go of all that tension; just let it go,” “Let it drain right into the floor,” or “Completely surrender to the pull of gravity.” The same posture can be practiced seated. EFTT therapists also help clients identify the sources of tension (worries, pressures, chronic resentment, obsessive thoughts) and include these in the practice. This can be implemented in response to specific in-session markers (e.g., obvious client physical tension or statements such as, “I know it’s pointless to worry, but I can’t let it go”) or at the beginning or end of a session. Clients can also be encouraged to take regular breaks during the day by simply resting their head on their arms crossed on their desk, identifying what they want to let go of, using whatever words help them let go of tension, attending to and relishing the experience. The concept of “surrender” can have negative connotations for some clients who find it synonymous with powerlessness and defeat—experiences typical of traumatic victimization. In these instances, therapists can help clients experience the difference between the collapse, crumpling, slumping posture of powerlessness and defeat and the long spine and release of a deliberate and intentional forward fold. Visualization and Imagery In yoga therapy, visualization and imagery are domains of practice typically used to symbolize, cue, or promote positive states. An example of visualization commonly used in trauma therapies, including EFTT, involves imagining “a safe place” before reexperiencing procedures or experiential focusing. EFTT also attends to the evocative metaphors that clients use to describe their current (and childhood) experience: “like falling off a cliff, completely powerless,” “a little girl in a dungeon,” “chained to my father’s anger,” “living in the trenches.” As noted in Chapter 5, these are windows into the client’s internal experience, providing access to feelings and meanings. However, when clients have difficulty identifying or allowing the implied emotional experience, it can be helpful to direct their attention to their embodied experience of these metaphors—sensations, posture, or breathing. Therapists empathically respond to the discomfort of a negative image and help clients to imagine how much better it would feel to “get out of the dungeon” or the “trenches,” for example. These are embodied therapeutic goals that are the basis for identifying heartfelt intentions (described in the next section) to motivate change. Yoga therapy recommends that client visualizations not be drawn from their personal stories to avoid preexisting associations. Intervention directs attention to the multimodal sensory experience of a visual image that should be accompanied by complementary breathing, hand postures, and words (a symbol or “handle”) to deepen and cue new desired experience. The names of many

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traditional yoga postures—child’s pose, mountain, goddess, warrior, eagle— evoke images that can be used to activate and deepen bodily experience. For example, a client who, after many sessions that focused on improving her self-confidence and esteem, decided she wanted to “take the plunge” and begin online dating. However, she found herself paralyzed by feelings of vulnerability and unable to even log on to dating sites. She described herself as “beige wallpaper”—totally uninteresting. When asked how she would like to feel, she responded “like a beautiful, strong diamond.” Although it would be important to first explore the specific connotations of a “diamond” the client liked, a yoga therapy practice to help her “shine” and embody this image (K. J. P. Robinson, personal communication, February 14, 2021) could encourage her to stand, slowly make figure eights with her hips to bring in flow and open space for light to come in, then open her arms wide to the sky imagining herself channeling light. The Garuda mudra for the strength of an eagle and grace also could be introduced. Such a practice would be collaboratively developed with the client, guiding her to attend to her positive experience and describe how this would affect her experience going on dating sites. Establish Intentions (Sankalpa) As noted earlier, helping clients to establish their sankalpa, or heartfelt intentions for how they want to be in the world, is consistent with the EFTT focus on clients’ wants, needs, desires, core values, and concerns (e.g., authenticity, connection to life and humanity, peace, and serenity) to help motivate positive action. Yoga therapy intervention to establish intentions encourages clients to place their hands on the heart and belly, feel their body breathing, and ask what their heart’s deepest desire is. How do they want to show up in the world? What kind of person do they want to be? This can refer to an intention for the day (as they leave the session), for a particular situation (e.g., the next time they see a difficult parent), or more generally. Importantly, this is accompanied by experientially imagining (see the earlier visualization) what it would be like to manifest this in their life—how it would feel, how life would be different. Intervention can help clients generate a symbol for their intention— a visual image, sound, or word—that can deepen, cue, and activate the experience. Generating such a symbol for positive experience frequently begins by attending to the more familiar and dominant opposite negative experience that emerges in session. Focus on Opposites of Experience Another tool used in yoga therapy to increase awareness of internal experience is to focus attention on opposites of experience. This technique is a central component of yoga nidra meditation, described in the following section (Miller, 2015). At the most basic level, for example, as a starting point for clients who are numb or severely cut off from their bodies, interventions

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facilitate awareness of opposite sensations—soft–hard, warm–cool, heavy–light, tense–relaxed, open–closed. This awareness of basic physical sensation generalizes to awareness of a more complex negative or uncomfortable state and the opposing positive or comfortable experience. Clients can be encouraged to describe a negative bodily experience and then generate images or symbols of the opposite positive or preferred state and viscerally experience both. For example, the client who wanted to feel like a diamond could be encouraged to first attend to the slumped, withdrawn bodily experience of feeling like “beige wallpaper.” This focus on experiencing opposites has obvious relevance to two-chair work in EFTT. When clients are stuck in a maladaptive emotion and adaptive self-protective capacities do not emerge, interventions can direct attention to the bodily experience of maladaptive fear or shame (tension, constriction, shrinking away) and then invite clients to adopt a posture or gesture to embody the more desired state and attend to that new embodied experience. For clients with poor body awareness or who are self-conscious, the principle of “practicing with” is critically important. Encouraging clients to deliberately go back and forth between producing the negative and positive experiences increases their awareness and agency. Meditation Yoga therapy includes a variety of meditation practices that can be integrated into EFTT. Structured meditation (vs. brief mindful observation of a specific experience) can be used at the beginning or end of sessions for different purposes. The most basic practice is mindful breathing, attending to the wave of inhaling and exhaling, movement of the belly, or following the flow of thoughts and feelings. Yoga-based guided meditations typically include images, metaphors, and references to nature that help emphasize the interconnection of all things—for example, the belly rising and falling with each breath like waves of the sea, the nourishment of the inhale and surrender of the exhale, the lightness of the inhale (lifting toward the sky) and grounding of the exhale (connecting to the earth). Yoga-based meditations are also typically multimodal. For example, yoga nidra is a structured practice promoting a state of deep relaxation. The foundation is a body scan and breath awareness, welcoming whatever thoughts and feelings emerge in this relaxed state, identifying and deeply experiencing a personal sankalpa, and using creative visualization or imagery to enhance experiences of wholeness, connectedness, harmony, peace, and joy. Importantly, yoga-based meditation practices in EFTT also focus on meaning and include an interactive component and/or processing with the therapist. Integrated restorative yoga nidra (Miller, 2015) for trauma, for example, specifically focuses on observing and welcoming painful feelings and memories related to traumatic experiences. In EFTT, these would be processed with the therapist, who also helps the client develop images and intentions specifically tailored to the individual.

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Compassion-based meditations have become important aspects of many current psychotherapeutic approaches (e.g., Gilbert, 2014) and popular culture (Brach, 2019). These are especially relevant to complex trauma clients who believe that kindness and compassion toward the self are self-indulgent and “babying.” “Loving-kindness” meditation, for example, is derived from Buddhist practice and has many variations that can be taught and flexibly integrated into the therapy process and tailored to individual clients’ needs. The standard protocol is a heartfelt wish for one’s (and others’) happiness, health, safety, and awareness of the preciousness of life. The yoga therapy approach can include generating an image or sound and adopting a hand posture or gesture to embody the wish or value. In EFTT, clients are encouraged to go slowly, deeply focus on and viscerally experience the effect of each wish, and assess the ones that particularly resonate or are particularly difficult and explore the difficulty. As in other practices, such early difficulties with positive experience can be a benchmark for change. Existential and Spiritual Practices Clients’ existential and spiritual beliefs and practices often emerge in the early phase of EFTT when assessing resilience, coping strategies, and how clients take care of themselves. Many clients identify with a particular faith, and many identify themselves as “spiritual but not religious.” Clients with a history of addictions, for example, who have been part of 12-step recovery programs have been encouraged to develop a belief in a “higher power.” These belief systems are associated with values such as loving-kindness, forgiveness, interconnectedness, community, and being “a child of God” or “a child of the universe” that can be drawn on as positive resources for change. As noted in Chapter  9 of this volume, clients who have difficulty soothing the self, for example, can be asked how a beloved spiritual figure would treat them or what they would want for them. Yoga-based interventions are designed to give clients a taste of these positive states—a sense of wholeness, peace, serenity, reverence for life—to know these experiences are possible and can be cultivated. Clients are also encouraged to engage with whatever experiences in their daily lives connect them with a sense of wonder—walking in nature, being with children, listening to music, reading poetry, visiting art galleries, connecting with supportive others and communities, or engaging in devotional practices.

BODY-BASED INTERVENTIONS OVER THE COURSE OF EFTT The following subsections describe how yoga therapy body-based interventions can be integrated into EFTT sessions over the course of therapy. Case examples illustrate how these interventions are used to address specific emotional processing difficulties.

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Phase 1 of EFTT: Focusing on Emotion The primary foci of the early phase of EFTT are to establish a strong therapeutic alliance and begin the process of deepening experiencing. Associated subtasks include assessing client processing difficulties and determining whether and how body-based intervention can help address these difficulties. Providing a Rationale for Body-Based Intervention As with all EFTT procedures, introducing body-based interventions requires providing a rationale tailored to the individual client’s goals and treatment needs and collaborative agreement on the value of these procedures in accomplishing client goals. There are numerous rationales for focusing on the body that will resonate with different clients depending on their perspective and most pressing concerns—for example, there is abundant evidence that trauma is embodied (neurobiological effects), the body is the most basic manifestation of our being and a source of information that can guide adaptive functioning, the body is an interpersonal communication system (body language) that signals to others our internal state and influences their reactions to us, and well-being means balance and attention to all domains of being rather than exclusively “living in our heads.” Recovery from trauma involves using all tools available, figuring out what works for you and what makes you feel happy and more alive, more the person you want to be. As with all EFTT procedures, the rationale for engagement in body-based interventions is typically brief. When procedures are introduced in response to in-session markers—when processes are “hot” and alive—most clients respond quickly. A more elaborate rationale and guidance are provided as needed. Of course, therapists need to be comfortable with body-based intervention and clear on how these are compatible with EFTT. Just as emotion-focused therapy chair work can initially seem strange and awkward to clients, the best predictor of client engagement in chair work and body-based practices is the therapist’s comfort with the interventions. In early sessions, EFTT can include explicit body-based skills training to address client difficulties with emotion dysregulation and limited awareness of internal experience. Structured interventions can be taught to help clients slow down, calm down, release tension, ground, and focus so they can better attend to internal experience. Guided meditations can be introduced in session and are available online for use between sessions for clients who wish to use them. These should be kept brief—5 to 10 minutes. Helping clients establish their heartfelt intentions and desires can also be introduced in early sessions. These can be further refined and referenced repeatedly over the course of therapy to help stay on track and motivate engagement and change. In many instances, clients with poor awareness of their internal experience (body and emotions) will require continued emotion coaching and practice throughout the therapy process. Some clients like and request structured homework and skills practice beyond the standard self-observation typically offered by EFT therapists. Once learned and personalized, aspects of these

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procedures can be integrated into the moment-by-moment process. Bodybased tools (breathing, postures, meditations, establishing intentions) can also be implemented at the end of a session to help the client leave the session in a productive state (e.g., feeling peaceful and strong, calm, energized, hopeful, with clear intentions for the rest of their day). Grounding and the Downregulation of Emotion The following case example illustrates the use of multiple body-based tools primarily aimed at emotion regulation in early sessions of EFTT. The client, Rebecca, came to therapy feeling desperate and exhausted, the sole breadwinner with two adolescent children, fearing financial ruin at the hands of her “gambling addict” husband. Rebecca described herself as having been “in the trenches” for several years dealing with financial and emotional instability. She grew up in a chaotic alcoholic home where she learned she could not trust anyone to take care of her. In her adult life, she was a highly driven professional, always on guard and overly responsible. During the first session, she was hyperverbal and dysregulated, repeatedly collapsing into tears as she described events from the recent past and fears for the future. Because empathic responding was minimally effective in helping her to downregulate, the therapist suggested a body-based intervention to help her slow down, get out of her head, and feel more grounded in the present before they could begin to explore and understand her issues. The intervention began with movement—gentle shaking of her arms and legs to “shake off the restless energy” of her mind. This was followed by guidance in slow belly breathing, directing her attention to and symbolizing her bodily experience (Client: I feel tension in my head and shoulders, like electric charges. Therapist: Like you are firing on all cylinders. Stay with that for a bit, Rebecca; just notice the sensations. Keep breathing. Yes, that’s good. What is going on now?). When Rebecca described a loosening of her tension, the therapist asked if she could imagine the opposite of that nervous energy. She quickly reported imagining sitting on a bench “in the French countryside.” Intervention then focused on grounding. She was guided to put her hand on her belly as she breathed, lengthening the exhale, then imagine breathing into her feet, then down into “the warm earth” (farther away from her head) as she continued to imagine sitting on the bench (Therapist: Can you describe your experience? Client: It’s like a sense of flow, with no blocks through my whole body. Therapist: Is there a word or symbol that captures your experience? Client: [pauses] Yes, “quiet,” I feel quiet [smiles]. Therapist: Ah, quiet; stay with that, really savor it.). Together, they agreed that this experience of “quiet” was missing in her life and something she deeply wanted to cultivate more of. In processing this experience at the end of the session, Rebecca said she loved the practice, understood the connection between her psychological and physical state, and liked the goal of achieving more “balance” between her head, heart, and body. She and the therapist collaborated on how she could spend a few moments focusing on this experience of “quiet” throughout the

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week, whenever she noticed the nervous energy in her body, to take a break from “the trenches.” She left the first session feeling “hopeful.” Later sessions began with a gentle shaking of her arms and legs, followed by a few minutes of practicing variations of her experience of “quiet” and grounding—for example, seated or standing mountain pose, focusing on the feeling of her feet on the floor, rooted like a tree, rising from the earth, relaxed and flexible. This helped her again shake off the restless energy of her daily life, then slow down and center so she could focus on exploring her feelings and needs during the session. Rebecca described herself as a “fighter”; this is how she had coped with trauma and stress her entire life. Her dominant emotional experience was anger, both adaptive and empowering, as well as defensive and covering a core sense of self as unsafe, with only herself to rely on. The middle phase of EFTT with Rebecca focused on helping her acknowledge and explore this core sense of self developed through growing up in a chaotic alcoholic home. Phase 2 of EFTT: Self-Related Difficulties The middle phase of EFTT focuses on reducing client fear and shame and addressing processing difficulties that interfere with engagement in EFTT interventions and resolution. The following subsections illustrate how body-based intervention can enhance these processes. Deepening Experiencing and Accessing Adaptive Experience One of the difficulties observed in EFTT is extreme client powerlessness and struggles with self-assertion (e.g., during IC). Body-based intervention aimed at increasing clients’ empowerment can begin by asking them to adopt any posture that helps them feel stable and strong. Some clients will be familiar with such postures through exercise programs or yoga classes; others will not and need to be taught. In either case, clients are encouraged to playfully experiment with power poses they like (in and between sessions) and attend to their experience of strength and empowerment to increase awareness and agency in producing this state. An example of the use of traditional yoga postures to enhance empowerment is the client, Amy, who had a history of anorexia and bulimia and grew up with a domineering and critical father and a profoundly depressed mother. Her mother died when the client was an adolescent, and the father remarried only a few months later. Amy felt angry and betrayed by this and disliked her stepmother. She was highly anxious and struggled with feeling invisible and disposable, helpless and powerless all her life. In session, for example, she was unable to express her anger toward her imagined father during IC, repeatedly collapsing into powerless weeping. One of her positive coping strategies was participation in regular yoga classes, and she was enthusiastic when her therapist suggested incorporating yoga into her therapy. Because her regular yoga practice focused on closed postures that helped her feel safe and calm, she and the therapist agreed to experiment with power poses to help increase her

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experience of strength and facilitate empowerment. This practice initially took place at the beginning of sessions, and aspects were later incorporated into the moment-by-moment process of therapy. Amy’s favorite yoga power posture was the traditional “goddess” pose (she particularly liked the symbolism), feeling the strength in her legs. The therapist encouraged her to experiment with and attend to her experience in different arm and gaze variations, movements, breathing, and sounds—for example, arms open, “cactus” arms, prayer hands, squatting slowly and deeply on the exhale accompanied by a calming “shhhh” sound, eyes open or closed, lion’s breath for “fierce goddess.” Amy reported discomfort with more open postures; she felt “anxiety in my chest.” The therapist validated her discomfort and encouraged her to adopt her most comfortable stance and to practice (at home) gradually moving out of her comfort zone. During later sessions, at markers of powerlessness and collapse, EFTT interventions referred to strengthening the powerful “goddess” part of herself and encouraged her to adopt a powerful posture, attend to the feeling, and speak from that strong place. Therapy also helped Amy establish an intention for how she wanted to be in the world. She identified wanting to be more “playful” rather than fearful and constricted and imagined herself dancing in a field of wildflowers with the warm sun shining on her. Amy was petite and often sat curled up on the therapy couch; during one session, the therapist encouraged her to “take up more space” in the office and the world. She stood up, adopted a wide stance, and began making large circles with her upper body and arms outstretched as far as she could. The therapist joined her in this playful movement, both laughing. Amy was gradually able to become more assertive in confronting her father, both during IC and in real life. Before the end of therapy, she also enrolled in a self-defense class for women. Body-Based Intervention to Enhance Two-Chair Dialogues The middle phase of EFTT also typically includes the use of two-chair dialogues to help reduce fear and avoidance of internal experience and shame. Bodybased interventions can augment these procedures to deepen experiencing, help clients shift out of negative states, and enhance healthy alternative positive experiences. One example of this kind of work is with the client Jeremy, who was shamed and humiliated in his family and bullied by his older brother. He came to therapy ambivalent about whether to stay in his current romantic relationship. He loved his girlfriend but disliked her past “baggage,” her previous intimate relationships; her “loose” behavior did not meet his moral standards. Early intervention included two-chair dialogues to explore this conflict between his “heart and his head,” but these explorations remained on an intellectual level. The therapist decided to abandon the two-chair procedure and continue exploration in the therapeutic relationship. Over time, Jeremy acknowledged feeling that his girlfriend’s past intimate relationships made him feel less “special.” He worried that he was a “loser” because he was not married yet and had had two previous rejections (shame–anxiety).

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He acknowledged, “Maybe if I had more confidence, it wouldn’t bother me so much.” He and the therapist agreed to focus on his insecure sense of self-worth as the core issue. Although he was increasingly open and vulnerable with the therapist (e.g., expressed sadness about never finding anyone to love), for several sessions, exploration of his self-worth remained largely intellectual. Jeremy came to Session 21 highly distressed, plagued by obsessive worry that his girlfriend was cheating on him and was going to humiliate him and make him look like a fool. Even though she denied it, he was unable to “get a handle on” his anxiety. The therapist suggested that a two-chair dialogue might help get at the root of things. Explicitly focusing on his bodily experience in this context helped deepen negative experience and access positive alternative experience. Jeremy first enacted the anxiety-producing part of himself that warned him not to trust his girlfriend—“You will be taken advantage of, then look like a fool,” and “This will be intolerable, destroy you.” The therapist directed his attention to his bodily experience in response to these warnings. Jeremy reported feeling small and constricted, with a heavy chest and shallow breath. The therapist then encouraged him to “stay with that,” asking questions such as “Do you like this feeling?” “Does it feel good?” “Does this feel comfortable?” “Is this how you want to be in life?” These elicited a strong response of protest (“No, I hate it. I do not want to spend my life like this!”). When the therapist asked him what would feel better and more comfortable, Jeremy immediately opened his arms wide and began breathing deeply. THERAPIST:

Wow, that must feel great. Stay with that good feeling, Jeremy. Can you imagine how your life would be if you could feel like that more?

CLIENT:

I would be more open, relaxed. . . . I think I would take more risks, be able to fully experience life.

THERAPIST:

Confident you could handle things.

CLIENT:

Yes, confident, free.

The therapist then invited him to tell the other part of himself (in the other chair) how important that would be to him to “speak from your heart.” Here Jeremy deeply experienced and expressed, for the first time, healthy needs for openness and engagement with life to help shift his pattern of fear, suspicion, and shame–anxiety. The intervention also helped Jeremy develop a visualization to deepen this positive experience. He imagined the peace of relaxing by a river in the mountains, in “paradise,” completely “open to the universe.” The therapist then invited him to imagine his girlfriend “just sitting beside you” on the riverbank. This elicited nervousness that the therapist validated, and the therapist encouraged him to stay with whatever image was comfortable. To promote awareness of agency, the intervention also encouraged him to shift back and forth between the parts of himself in the two chairs—fearful warnings that created shrinking

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and constriction and the alternate body posture, desire, and image that created an experience of openness and confidence. At the end of the session, Jeremy reported that the session felt like a breakthrough for him. The therapist encouraged him to adopt the open-hearted posture and deep breathing, recall this image, and focus on his heartfelt intention when he noticed anxious distrusting thoughts and the accompanying bodily constriction between sessions. At the beginning of the following session, Jeremy reported continuing the in-session practice and being “pleased” that he experienced much less anxiety during the week. When the therapist reintroduced his body posture and visualization, he was able to allow his girlfriend to “sit beside him by the river.” He felt confident he could handle whatever came his way. Jeremy concluded that he was “too dependent on others’ approval” and wanted to focus future sessions on being more confident within himself. He and the therapist agreed to focus on healing “old wounds from the past” to help him accomplish this goal. Again, attention to his bodily experience continued to be an important part of EFTT interventions to activate, explore, and strengthen his sense of self-worth. Another case example illustrates the use of a loving-kindness meditation in conjunction with EFTT interventions to strengthen a client’s limited capacity for self-compassion. Iris’s parents were survivors of a brutal revolution. Harsh parenting, including physical discipline, particularly from her mother, was intended to toughen her up so she could survive in the world. Iris came to therapy to deal with current PTSD from repeated exposure to suffering and violence in the workplace (vicarious traumatization) and viewed her symptoms as unacceptable signs of weakness. She berated herself for being “too sensitive” and tried to suppress her vulnerable feelings. She and the therapist agreed that these were internalized messages from her mother that were intended to strengthen her, but they were not working; in fact, they were exacerbating her PTSD symptoms. Two-chair dialogues increased Iris’s awareness of how she was “hurting” herself with self-criticism and relentless pressuring and activated a desire to be less harsh. Memory work accessed deep sadness as she recalled how hard she tried to please her mother as a child. She acknowledged her mother’s acceptance and valuing as core unmet needs. Iris intellectually understood the positive effect this would have had on her development as a child but had difficulty accepting her vulnerability as an adult. At the end of one session, the therapist suggested teaching her a “loving-kindness” meditation to help her cultivate a more nurturing stance toward herself. Repeating the words “May I be happy” quickly activated Iris’s difficulties—she felt uncomfortable expressing a wish for her happiness or even giving herself permission to be happy. Many clients experience embarrassment at such “babying,” others believe that such “pampering” is self-centered, and still others experience this as pointless “wishful thinking.” Therapists typically help clients explore their resistance using basic EFTT interventions described in earlier chapters of this volume. It can be helpful for clients to understand that the loving-kindness meditation is not about cultivating a feeling of love toward the self but a commitment to treat

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oneself (and ultimately others) with kindness and respect. In this instance, the therapist invited Iris to explore her discomfort (“Somehow it is unacceptable for you to wish good things for yourself. It is like you have bought into your mother’s belief system”). Iris was surprised and saddened by this realization (Client: Of course, I want to be happy, at least some of the time! Therapist: Yes, certainly more than you are now. Let’s see if we can get clear on what more happiness would mean for you right now). Here, Iris identified her authentic wishes and desires for less pressure and stress in her life, which became the basis for her personalized loving-kindness meditation: “May I be free from pressure. May I be free from stress and fear. May I be at ease.” These words sat well with her. Consistent with EFTT and yoga therapy principles, this meditation included imagining how she could realize these heartfelt intentions in her life and viscerally experience how her life would be different in terms of her feelings, behaviors, and relationships if they were realized. As Iris and the therapist continued to explore her past and current struggles, these healthy desires were repeatedly referenced as touchstones to help motivate change. Iris also began a brief practice of beginning her day with this meditation—anticipating events of the day and imagining how she could approach them concretely, with a more self-compassionate stance. As Iris approached the end of therapy, she was pleased to report including her mother in her loving-kindness meditation, and eventually, she decided she no longer wanted to work in such a stressful environment. Phase 3 of EFTT: Difficulties Related to the “Other” The late phase of EFTT begins once clients can fully experience adaptive emotion and associated meanings. Body-based interventions at this phase are not used to help address processing difficulties because these have largely been resolved. However, intervention can direct client attention to the visceral experience of empowerment associated with adaptive anger and relief or surrender associated with sadness and acceptance of loss, as well as the changes they have accomplished over the course of therapy. This bodily experience can help consolidate change, especially when body-based intervention has been a prominent part of the client’s therapeutic process. As clients approach resolution, they can be asked to compare their current experience with those early on in therapy—for example, assertive versus rejecting anger, letting tears wash over them versus “holding back the river,” acceptance versus resignation or fighting to change the other, and reactivity to triggers versus feeling grounded and balanced. Resolution might consist of new experiences of forgiveness or compassion for the other, and clients can be encouraged to adopt postures, gestures, and breathing that reflect these new positive experiences—for example, opening their arms, imagining welcoming the other into their heart, making a gesture of offering, or setting the other free—and verbally symbolize the meaning of these gestures. Finally, clients can be asked to attend to and describe the embodied experience of being “finished,” at peace in terms of their earlier struggles and relationship with the other.

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At the most basic level, termination includes reviewing clients’ present symptom status. PTSD, anxiety, and depression are associated with obvious physiological experiences, and likewise, so is their reduction. Body-based interventions can deepen experiencing by focusing attention on improved breath regulation and the pleasant bodily experience of changes (e.g., feeling reduced tension, feeling lighter, having more energy and vitality, having ease of movement) and highlighting client agency in producing positive feelings. Termination also includes reviewing the client’s early heartfelt intentions (e.g., to be more playful, quiet, open hearted, self-compassionate) and checking how these may have evolved over the course of therapy and their current experience. Intervention directs attention to the embodied experience of being in harmony with one’s core values and standards, being more “the kind of person one wants to be,” and possibly identifying what remains to be done. In bridging to the future, as clients anticipate and imagine future potentially troubling situations, body-based interventions can help strengthen client agency in producing positive experience. Clients can be encouraged to develop an intention for the future and imagine how they might manifest this in their life in the future and how it would feel. In conclusion, this appendix is a brief introduction to yoga therapy theory and practice and ongoing explorations of how these body-based principles can be integrated into EFTT. Successful integration requires, first and foremost, maintaining a focus on the overarching principles of change in EFTT. These principles are (a) a compassionate and collaborative therapeutic relationship and (b) emotional experiencing and transformation—accessing and exploring feelings and meanings and constructing new meaning from this process. New meaning comes from accessing and integrating new adaptive emotion and meanings into maladaptive emotion structures or schemes. Successful integration of yoga therapy (or any divergent approach) into EFTT requires a clear understanding of the following: (a) what specific features of yoga theory and intervention are compatible with EFTT, (b) why a specific yoga therapy intervention is relevant (i.e., the specific emotional processing difficulty it is intended to address) and when to implement it (i.e., the specific in-session marker), and finally, (c) how to implement and seamlessly assimilate specific yoga therapy practices into the EFTT therapy process. When these criteria are in place, therapy can be a creative, exploratory, collaborative process between the therapist and client. It is hoped that this addendum will foster continued research and practice to further refine and evaluate the EFTT treatment model. Such developments will help clinicians of all orientations better meet the needs of individual clients dealing with the devastating effects of complex relational trauma. REFERENCES Adele, D. (2009). The yamas and niyamas: Exploring yoga’s ethical practice. On-Word Bound Books. Brach, T. (2019). Radical compassion: Learning to love yourself and your world with the practice of RAIN. Viking.

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Capon, H., O’Shea, M., Evans, S., & McIver, S. (2021). Yoga complements cognitive behaviour therapy as an adjunct treatment for anxiety and depression: Qualitative findings from a mixed-methods study. Psychology and Psychotherapy, 94(4), 1015–1035. https://doi.org/10.1111/papt.12343 Clark, C. J., Lewis-Dmello, A., Anders, D., Parsons, A., Nguyen-Feng, V., Henn, L., & Emerson, D. (2014). Trauma-sensitive yoga as an adjunct mental health treatment in group therapy for survivors of domestic violence: A feasibility study. Complementary Therapies in Clinical Practice, 20(3), 152–158. https://doi.org/10.1016/ j.ctcp.2014.04.003 Devi, N. J. (2007). The secret power of yoga: A women’s guide to the heart and spirit of the Yoga Sutras. Harmony. Emerson, D., & Hopper, E. (2011). Overcoming trauma through yoga: Reclaiming your body. North Atlantic Books. Emerson, D., Sharma, R., Chowdry, S., & Turner, J. (2009). Trauma-sensitive yoga: Principles, practice, and research. International Journal of Yoga Therapy, 19(1), 123–128. https://doi.org/10.17761/ijyt.19.1.h6476p8084l22160 Ford, J. D. (2020). Developmental neurobiology. In J. D. Ford & C. A. Courtois (Eds.), Treating complex traumatic stress disorders in adults (2nd ed., pp. 35–61). Guilford Press. Gayner, B. (2019). Emotion-focused mindfulness therapy. Person-Centered and Experiential Psychotherapies, 18(1), 98–120. https://doi.org/10.1080/14779757.2019.1572026 Gerber, M. M., Kilmer, E. D., & Callahan, J. L. (2018). Psychotherapeutic yoga demonstrates immediate positive effects. Practice Innovations, 3(3), 212–225. https://doi.org/10.1037/ pri0000074 Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6–41. https://doi.org/10.1111/bjc.12043 Hayes, S., Strosahl, K., & Wilson, K. (2012). Acceptance and commitment therapy (2nd ed.). Guilford Press. Kabat-Zinn, J. (1990). Full catastrophe living. Delta Press. Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8(2), 73–107. Le Page, J., & Le Page, L. (2013). Mudras for healing and transformation. Integrative Yoga Therapy. Linehan, M. (2015). DBT skills training manual (2nd ed.). Guilford Press. Miller, R. (2015). The iRest program for healing PTSD: A proven-effective approach to using yoga nidra meditation and deep relaxation techniques to overcome trauma. New Harbinger Publications. Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. Guilford Press. Paivio, S. C., Jarry, J. L., Chagigiorgis, H., Hall, I., & Ralston, M. (2010). Efficacy of two versions of emotion-focused therapy for resolving child abuse trauma. Psychotherapy Research, 20(3), 353–366. https://doi.org/10.1080/10503300903505274 Porges, S. W., & Dana, D. A. (2018). Clinical applications of the polyvagal theory: The emergence of polyvagal-informed therapies. Norton. Reinhardt, K. M., Noggle Taylor, J. J., Johnston, J., Zameer, A., Cheema, S., & Khalsa, S. B. S. (2018). Kripalu yoga for military veterans with PTSD: A randomized trial. Journal of Clinical Psychology, 74(1), 93–108. https://doi.org/10.1002/jclp.22483 Robinson, K. J. P. (2021). Yoga for anxiety and trauma. https://www.katlinrobinson.com Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse (2nd ed.). Guilford Press. Simon, N. M., Hofmann, S. G., Rosenfield, D., Hoeppner, S. S., Hoge, E. A., Bui, E., & Khalsa, S. B. S. (2021). Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: A randomized clinical trial. JAMA Psychiatry, 78(1), 13–20. https://doi.org/10.1001/jamapsychiatry.2020.2496

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Smith, S. E., & Ford, J. D. (2020). Complementary healing therapies. In J. D. Ford & C. A. Courtois (Eds.), Treating complex traumatic stress disorders in adults (pp. 569–590). Guilford Press. van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking. van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M., & Spinazzola, J. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: A randomized controlled trial. The Journal of Clinical Psychiatry, 75(6), e559–e565. https://doi. org/10.4088/JCP.13m08561 Weintraub, A. (2003). Yoga for depression: A compassionate guide to relieve suffering through yoga. Harmony.

REFERENCES

Abbass, A. A., & Town, J. M. (2013). Key clinical processes in intensive short-term dynamic psychotherapy. Psychotherapy, 50(3), 433–437. https://doi.org/10.1037/ a0032166 Adele, D. (2009). The yamas and niyamas: Exploring yoga’s ethical practice. On-Word Bound Books. Afifi, T. O., MacMillan, H. L., Boyle, M., Taillieu, T., Cheung, K., & Sareen, J. (2014). Child abuse and mental disorders in Canada. Canadian Medical Association Journal, 186(9), 324–332. https://doi.org/10.1503/cmaj.131792 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Angus, L., Boritz, T., & Carpenter, N. (2013). Narrative, emotion and meaning making in psychotherapy: From theoretical concepts to empirical research findings. Psychiatry and Psychotherapy, 32(4), 329–338. Angus, L., Boritz, T., Mendes, I., & Goncalves, M. M. (2019). Narrative change processes and client treatment outcomes in emotion-focused therapy. In R. N. Goldman & L. S. Greenberg (Eds.), Clinical handbook of emotion-focused therapy (pp. 243–260). American Psychological Association. https://doi.org/10.1037/ 0000112-011 Angus, L. (Host), & Paivio, S. C. (Therapist). (2015). Narrative processes in emotionfocused therapy for trauma [Film; educational DVD]. American Psychological Association. https://www.apa.org/pubs/videos/4310940.aspx Angus, L. E., Boritz, T., Bryntwick, E., Carpenter, N., Macaulay, C., & Khatna, J. (2017). The Narrative-Emotion Process Coding System 2.0: A multi-methodological approach to identifying and assessing narrative-emotion process markers in psychotherapy. Psychotherapy Research, 27(3), 253–269. https://doi.org/10.1080/ 10503307.2016.1238525  335

336  References

Arntz, A., Tiesema, M., & Kindt, M. (2007). Treatment of PTSD: A comparison of imaginal exposure with and without imagery rescripting. Journal of Behavior Therapy and Experimental Psychiatry, 38(4), 345–370. https://doi.org/10.1016/ j.jbtep.2007.10.006 Askeland, I. R., & Heir, T. (2014). Psychiatric disorders among men voluntarily in treatment for violent behaviour: A cross-sectional study. BMJ Open, 4(4), Article e004485. https://doi.org/10.1136/bmjopen-2013-004485 Bartholomew, K. (1993). From childhood to adult relationships: Attachment theory and research. In S. Duck (Ed.), Understanding relationship processes: Vol. 2. Learning about relationships (pp. 30–62). SAGE. Bateman, A., & Fonagy, P. (2013). Impact of clinical severity on outcomes of mentalisation-based treatment for borderline personality disorder. The British Journal of Psychiatry, 203(3), 221–227. https://doi.org/10.1192/bjp.bp.112.121129 Beck, J. S. (2021). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press. Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality disorders (2nd ed.). Guilford Press. Blow, A. J., Curtis, A. F., Wittenborn, A. K., & Gorman, L. (2015). Relationship problems and military related PTSD: The case for using emotionally focused therapy for couples. Contemporary Family Therapy, 37(3), 261–270. https://doi.org/ 10.1007/s10591-015-9345-7 Boelen, P. A., Van den Hout, M. A., & van den Bout, J. (2006). A cognitive–behavioral conceptualization of complicated grief. Clinical Psychology: Science and Practice, 13(2), 109–128. https://doi.org/10.1111/j.1468-2850.2006.00013.x Bolger, E. A. (1999). Grounded theory analysis of emotional pain. Psychotherapy Research, 9(3), 342–362. https://doi.org/10.1080/10503309912331332801 Bowlby, J. (1988). A secure base. Basic Books. Brach, T. (2019). Radical compassion: Learning to love yourself and your world with the practice of RAIN. Viking. Cabrera, C., Torres, H., & Harcourt, S. (2020). The neurological and neuropsychological effects of childhood maltreatment. Aggression and Violent Behavior, 54, Article 101408. https://doi.org/10.1016/j.avb.2020.101408 Callahan, J. L., Maxwell, K., & Janis, B. M. (2019). The role of over-general memories in PTSD and implications for treatment. Journal of Psychotherapy Integration, 29(1), 32–41. https://doi.org/10.1037/int0000116 Capon, H., O’Shea, M., Evans, S., & McIver, S. (2021). Yoga complements cognitive behaviour therapy as an adjunct treatment for anxiety and depression: Qualitative findings from a mixed-methods study. Psychology and Psychotherapy, 94(4), 1015–1035. https://doi.org/10.1111/papt.12343 Carpenter, N., Angus, L., Paivio, S., & Byrntwick, E. (2016). Narrative and emotion integration processes in emotion-focused therapy for complex trauma: An exploratory process-outcome analysis. Person-centered and Experiential Psychotherapies, 15, 67–94. https://doi.org/10.1080/14779757.2015.113276 Chagigiorgis, H. (2009). The contribution of emotional engagement with trauma material to outcome in two version of emotions focused therapy for trauma (EFTT) [Unpublished doctoral dissertation]. University of Windsor. Chagigiorgis, H., & Paivio, S. C. (2006). Forgiveness as an outcome in emotion focused therapy for adult survivors of childhood abuse (EFT-AS). In W. Malcolm, N. DeCourville, & K. Belicki (Eds.), Women’s perspectives on forgiveness and

References 337

reconciliation: The complexities of restoring power and connection (pp. 121–141). Routledge, Taylor & Francis Group. Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965–971. https://doi.org/10.1037/ 0022-006X.73.5.965 Clark, C. J., Lewis-Dmello, A., Anders, D., Parsons, A., Nguyen-Feng, V., Henn, L., & Emerson, D. (2014). Trauma-sensitive yoga as an adjunct mental health treatment in group therapy for survivors of domestic violence: A feasibility study. Complementary Therapies in Clinical Practice, 20(3), 152–158. https://doi.org/ 10.1016/j.ctcp.2014.04.003 Cloitre, M., Cohen, L., & Koenen, K. C. (2006). Treating survivors of childhood abuse: Psychotherapy for the interrupted life. Guilford Press. Cloitre, M., Cohen, L. R., Ortigo, K., Jackson, C. L., & Koenen, K. (2019). Treating survivors of childhood abuse: Psychotherapy for the interrupted life. Guilford Press. Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70(5), 1067–1074. https://doi.org/10.1037/0022-006X.70.5.1067 Courtois, C., Ford, J., Cloitre, M., & Schnyder, U. (2020). Best practices in psychotherapy for adults. In J. D. Ford & C. Courtois (Eds.), Treating complex traumatic stress disorders in adults (2nd ed., pp. 62–98). Guilford Press. Courtois, C. A., Sonis, J., Brown, L. S., Cook, J., Fairbank, J. A., Friedman, M., Gone, J. P., Jones, R., La Greca, A., Mellman, T., Roberts, J., & Schulz, P. (2017). Clinical practice guidelines for the treatment of posttraumatic stress disorder (PTSD) in adults. American Psychological Association. https://www.apa.org/ptsd-guideline/ ptsd.pdf Cox, K. S., Resnick, H. S., & Kilpatrick, D. G. (2014). Prevalence and correlates of posttrauma distorted beliefs: Evaluating DSM-5 PTSD expanded cognitive symptoms in a national sample. Journal of Traumatic Stress, 27(3), 299–306. https:// doi.org/10.1002/jts.21925 Currier, J. M., Irish, J. E. F., Neimeyer, R. A., & Foster, J. D. (2015). Attachment, continuing bonds, and complicated grief following violent loss: Testing a moderated model. Death Studies, 39(4), 201–210. https://doi.org/10.1080/07481187. 2014.975869 Damasio, A. (2010). Self comes to mind: Constructing the conscious brain. Pantheon/ Random House. Damasio, A. R. (1999). The feeling of what happens: Body and emotion in the making of consciousness. Harcourt. Devi, N. J. (2007). The secret power of yoga: A woman’s guide to the heart and spirit of the Yoga Sutras. Harmony. Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. Routledge. https://doi.org/ 10.4324/9780203804377 Eckman, P., & Friesen, V. W. (1975). Unmasking the face: A guide to recognizing emotions from facial cues. Prentice-Hall. Elliott, R., & Shahar, B. (2019). Emotion-focused therapy for social anxiety. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 337–360). American Psychological Association. https://doi.org/ 10.1037/0000112-015

338  References

Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion focused therapy: A process experiential approach to change. American Psychological Association. https://doi.org/10.1037/10725-000 Emerson, D., & Hopper, E. (2011). Overcoming trauma through yoga: Reclaiming your body. North Atlantic Books. Emerson, D., Sharma, R., Chowdry, S., & Turner, J. (2009). Trauma-sensitive yoga: Principles, practice, and research. International Journal of Yoga Therapy, 19(1), 123–128. https://doi.org/10.17761/ijyt.19.1.h6476p8084l22160 Fairbairn, W. R. D. (1952). Psychoanalytic studies of the personality. Routledge. Fernandez, E. (Ed.). (2016). Treatments for anger in specific populations: Theory, application, and outcome. Oxford University Press. Foa, E., Hembree, E., Rothbaum, J., & Rauch, S. A. M. (2019). Prolonged exposure for PTSD: Emotional processing of traumatic experiences (2nd ed.). Oxford University Press. Ford, J. D. (2020). Developmental neurobiology. In J. D. Ford & C. A. Courtois (Eds.), Treating complex traumatic stress disorders in adults (2nd ed., pp. 35–61). Guilford Press. Ford, J. D., & Courtois, C. A. (Eds.). (2020). Treating complex traumatic stress disorders in adults (2nd ed.). Guilford Press. Fosha, D. (Ed.). (2021). Undoing aloneness and the transformation of suffering into flourishing: AEDP 2.0. American Psychological Association. https://doi.org/10.1037/ 0000232-000 Fosha, D., & Thoma, N. (2020). Metatherapeutic processing supports the emergence of flourishing in psychotherapy. Psychotherapy, 57(3), 323–339. https:// doi.org/10.1037/pst0000289 Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist, 56(3), 218–226. https://doi.org/10.1037//0003-066x.56.3.218 Freud, S. (1961). New introductory lectures. In The standard edition of the complete psychological works of Sigmund Freud (Vol. 22; J. Strachey, Ed. & Trans.; pp. 3–182). Hogarth Press. (Original work published 1933) Frijda, N. H. (2016). The evolutionary emergence of what we call “emotions.” Cognition and Emotion, 30(4), 609–620. https://doi.org/10.1080/02699931.2016.1145106 Gayner, B. (2019). Emotion-focused mindfulness therapy. Person-Centered and Experiential Psychotherapies, 18(1), 98–120. https://doi.org/10.1080/14779757. 2019.1572026 Gendlin, E. T. (1996). Focusing-oriented psychotherapy: A manual of experiential method. Guilford Press. George, C., Kaplan, M., & Main, M. (1985). Adult Attachment Interview. University of California. Gerber, M. M., Kilmer, E. D., & Callahan, J. L. (2018). Psychotherapeutic yoga demonstrates immediate positive effects. Practice Innovations, 3(3), 212–225. https://doi.org/10.1037/pri0000074 Gilbert, P. (2014). The origins and nature of compassion focused therapy. British Journal of Clinical Psychology, 53(1), 6–41. https://doi.org/10.1111/bjc.12043 Goetter, E. M., Bui, E., Ojserkis, R. A., Zakarian, R. J., Brendel, R. W., & Simon, N. M. (2015). A systematic review of dropout from psychotherapy for posttraumatic stress disorder among Iraq and Afghanistan combat veterans. Journal of Traumatic Stress, 28(5), 401–409. https://doi.org/10.1002/jts.22038

References 339

Goldman, R. N. (2019). History and overview of emotion-focused therapy. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 3–35). American Psychological Association. https://doi.org/10.1037/ 0000112-001 Goldman, R. N., & Greenberg, L. S. (2015). Case formulation in emotion-focused therapy: Cocreating clinical maps of change. American Psychological Association. https://doi.org/10.1037/14523-000 Gottman, J. M. (1997). The heart of parenting: Raising an emotionally intelligent child. Simon & Schuster. Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings. American Psychological Association. https://doi.org/10.1037/ 10447-000 Greenberg, L. S. (2019). Theory of functioning in emotion-focused therapy. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 37–59). American Psychological Association. https://doi.org/ 10.1037/0000112-002 Greenberg, L. S., & Bolger, E. (2001). An emotion-focused approach to the overregulation of emotion and emotional pain. Journal of Clinical Psychology, 57(2), 197–211. https://doi.org/10.1002/1097-4679(200102)57:23.0. CO;2-O Greenberg, L. S., & Foerster, F. S. (1996). Task analysis exemplified: The process of resolving unfinished business. Journal of Consulting and Clinical Psychology, 64(3), 439–446. https://doi.org/10.1037/0022-006X.64.3.439 Greenberg, L. S., & Goldman, R. N. (Eds.). (2019a). Clinical handbook of emotionfocused therapy. American Psychological Association. https://doi.org/10.1037/ 0000112-000 Greenberg, L. S., & Goldman, R. N. (2019b). Theory of practice of emotion-focused therapy. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotionfocused therapy (pp. 61–90). American Psychological Association. https://doi.org/ 10.1037/0000112-003 Greenberg, L. S., & Hirscheimer, K. (1994, February). Relating degree of resolution of unfinished business to outcome [Paper presentation]. North American Society for Psychotherapy Research Meeting, Santa Fe, NM, United States. Greenberg, L. S., & Malcolm, W. (2002). Resolving unfinished business: Relating process to outcome. Journal of Consulting and Clinical Psychology, 70(2), 406–416. https://doi.org/10.1037/0022-006X.70.2.406 Greenberg, L. S., & Paivio, S. C. (1997). Working with emotions in psychotherapy. Guilford Press. Greenberg, L. S., & Pascual-Leone, A. (2006). Emotion in psychotherapy: A practicefriendly research review. Journal of Clinical Psychology, 62(5), 611–630. https:// doi.org/10.1002/jclp.20252 Greenberg, L. S., Rice, L. N., & Elliott, R. K. (1993). Facilitating emotional change: The moment-by-moment process. Guilford Press. Greenberg, L. S., Warwar, S. H., & Malcolm, W. M. (2008). Differential effects of emotion-focused therapy and psychoeducation in facilitating forgiveness and letting go of emotional injuries. Journal of Counseling Psychology, 55(2), 185–196. https://doi.org/10.1037/0022-0167.55.2.185 Greenberg, L. S., & Watson, J. (2006). Emotion-focused therapy for depression. American Psychological Association. https://doi.org/10.1037/11286-000

340  References

Gross, J. J. (Ed.). (2015). Handbook of emotion regulation (2nd ed.). Guilford Press. Hamlat, E. J., & Alloy, L. B. (2018). Autobiographical memory as a target of intervention: Increasing specificity for therapeutic gain. Practice Innovations, 3(4), 227–241. https://doi.org/10.1037/pri0000075 Harrington, S., Pascual-Leone, A., Paivio, S., Edmondstone, C., & Baher, T. (2021). Depth of experiencing and therapeutic alliance: What predicts outcome for whom in emotion-focused therapy for trauma? Psychology and Psychotherapy: Theory, Research and Practice, 94(4), 895–914. https://doi.org/10.1111/papt.12342 Harrison, R. L., & Westwood, M. J. (2009). Preventing vicarious traumatization of mental health therapists: Identifying protective practices. Psychotherapy, 46(2), 203–219. https://doi.org/10.1037/a0016081 Harvey, A. G., Bryant, R. A., & Tarrier, N. (2003). Cognitive behaviour therapy for posttraumatic stress disorder. Clinical Psychology Review, 23(3), 501–522. https:// doi.org/10.1016/S0272-7358(03)00035-7 Hayes, S., Strosahl, K., & Wilson, K. (2012). Acceptance and commitment therapy (2nd ed.). Guilford Press. Hébert, M., Cénat, J. M., Blais, M., Lavoie, F., & Guerrier, M. (2016). Child sexual abuse, bullying, cyberbullying, and mental health problems among high school students: A moderated mediated model. Depression and Anxiety, 33(7), 623–629. https://doi.org/10.1002/da.22504 Hembree, E., & Foa, E. (2020). Prolonged exposure therapy. In J. Ford & C. Courtois (Eds.), Treating complex traumatic stress disorders in adults (pp. 207–225). Guilford Press. Herman, J. L. (1992). Trauma and recovery. Basic Books. Herman, J. L. (2019). Forward. In J. Ford & C. Courtois (Eds.), Treating complex traumatic stress disorders in adults (pp. xi–xvi). Guilford Press. Herrmann, I. R., Greenberg, L. S., & Auszra, L. (2016). Emotion categories and patterns of change in experiential therapy for depression. Psychotherapy Research, 26(2), 178–195. https://doi.org/10.1080/10503307.2014.958597 Holowaty, K. A. M., & Paivio, S. C. (2012). Characteristics of client-identified helpful events in emotion-focused therapy for child abuse trauma. Psychotherapy Research, 22(1), 56–66. https://doi.org/10.1080/10503307.2011.622727 Horvath, A. O., & Greenberg, L. S. (1989). Development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36(2), 223–233. https://doi.org/10.1037/0022-0167.36.2.223 Horvath, A. O., & Symonds, B. D. (1991). Relations between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139–149. https://doi.org/10.1037/0022-0167.38.2.139 Ingram, R. E., & Price, J. M. (Eds.). (2010). Vulnerability to psychopathology: Risk across the lifespan (2nd ed.). Guilford Press. Izard, C. (1977). Human emotions. Plenum. https://doi.org/10.1007/978-1-48992209-0 Izard, C. E. (2002). Translating emotion theory and research into preventive interventions. Psychological Bulletin, 128(5), 796–824. https://doi.org/10.1037/00332909.128.5.796 Jackson, C., Nissenson, K., & Cloitre, M. (2020). Cognitive-behavioral therapy. In J. Ford & C. Courtois (Eds.), Treating complex traumatic stress disorders in adults (pp. 370–389). Guilford Press. Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. Free Press.

References 341

Jaycox, L. H., Foa, E. B., & Morral, A. R. (1998). Influence of emotional engagement and habituation on exposure therapy for PTSD. Journal of Consulting and Clinical Psychology, 66(1), 185–192. https://doi.org/10.1037/0022-006X.66.1.185 Johnson, M. W., Hendricks, P. S., Barrett, F. S., & Griffiths, R. R. (2019). Classic psychedelics: An integrative review of epidemiology, therapeutics, mystical experience, and brain network function. Pharmacology & Therapeutics, 197, 83–102. https://doi.org/10.1016/j.pharmthera.2018.11.010 Johnson, S. (2002). Emotionally focused couples therapy for trauma survivors. Guilford Press. Jowett, S., Karatzias, T., Shevlin, M., & Albert, I. (2020). Differentiating symptom profiles of ICD-11 PTSD, complex PTSD, and borderline personality disorder: A latent class analysis in a multiply traumatized sample. Personality Disorders: Theory, Research, and Treatment, 11(1), 36–45. https://doi.org/10.1037/per0000346 Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. Delacorte. Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8(2), 73–107. Katz, C., & Fallon, B. (2020). Protecting children from maltreatment during COVID-19. Child Abuse & Neglect, 110(Pt. 2), Article 104753. https://doi.org/ 10.1016/j.chiabu.2020.104753 Kellner, R., Neidhardt, J., Krakow, B., & Pathak, D. (1992). Changes in chronic nightmares after one session of desensitization or rehearsal instructions. The American Journal of Psychiatry, 149(5), 659–663. https://doi.org/10.1176/ ajp.149.5.659 Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Benjet, C., Bromet, E. J., Cardoso, G., Degenhardt, L., de Girolamo, G., Dinolova, R. V., Ferry, F., Florescu, S., Gureje, O., Haro, J. M., Huang, Y., Karam, E. G., Kawakami, N., Lee, S., Lepine, J. P., Levinson, D., . . . Koenen, K. C. (2017). Trauma and PTSD in the WHO world mental health surveys. European Journal of Psychotraumatology, 8(Suppl. 5), Article 1353383. https://doi.org/10.1080/20008198.2017.1353383 Khayyat-Abuaita, U., Paivio, S., Pascual-Leone, A., & Harrington, S. (2019). Emotional processing of trauma narratives is a predictor of outcome in emotionfocused therapy for complex trauma. Psychotherapy, 56(4), 526–536. https:// doi.org/10.1037/pst0000238 Kiesler, D. J. (1971). Patient experiencing and successful outcome in individual psychotherapy of schizophrenics and psychoneurotics. Journal of Consulting and Clinical Psychology, 37(3), 370–385. https://doi.org/10.1037/h0031963 Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. Journal of Traumatic Stress, 26(5), 537–547. https://doi.org/10.1002/jts.21848 Klein, M. H., Mathieu-Coughlan, P., & Kiesler, D. J. (1986). The Experiencing Scales. In L. S. Greenberg & W. M. Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 21–71). Guilford Press. Köhler, C., Carvalho, A., Alves, G., McIntyre, R., Hyphantis, T., & Cammarota, M. (2015). Autobiographical memory disturbances in depression: A novel therapeutic target? Neural Plasticity, 2015, Article 759139. https://doi.org/10.1155/2015/759139 Kohut, H. (1984). How does analysis cure? University of Chicago Press. https:// doi.org/10.7208/chicago/9780226006147.001.0001

342  References

Kramer, U., Pascual-Leone, A., Berthoud, L., de Roten, Y., Marquet, P., Kolly, S., Despland, J. N., & Page, D. (2016). Assertive anger mediates effects of dialectical behavior-informed skills training for borderline personality disorder: A randomized controlled trial. Clinical Psychology & Psychotherapy, 23(3), 189–202. https:// doi.org/10.1002/cpp.1956 Krediet, E., Bostoen, T., Breeksema, J., van Schagen, A., Passie, T., & Vermetten, E. (2020). Reviewing the potential of psychedelics for the treatment of PTSD. The International Journal of Neuropsychopharmacology, 23(6), 385–400. https:// doi.org/10.1093/ijnp/pyaa018 Lane, R. D., & Nadel, L. (Eds.). (2020). Neuroscience of enduring change: Implications for psychotherapy. Oxford University Press. https://doi.org/10.1093/ oso/9780190881511.001.0001 Lanius, R. A., Williamson, P. C., Densmore, M., Boksman, K., Neufeld, R. W., Gati, J. S., & Menon, R. S. (2004). The nature of traumatic memories: A 4-T FMRI functional connectivity analysis. The American Journal of Psychiatry, 161(1), 36–44. https://doi.org/10.1176/appi.ajp.161.1.36 LeDoux, J. (2012). Rethinking the emotional brain. Neuron, 73(4), 653–676. https:// doi.org/10.1016/j.neuron.2012.02.004 Le Page, J., & Le Page, L. (2013). Mudras for healing and transformation. Integrative Yoga Therapy. Levy, K. N., Mehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarking, J. F., & Kernberg, O. F. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74, 1027–1040. https://doi.org/10.1037/0022-006X.74.6.1027 Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press. Linehan, M. (2015). DBT skills training manual (2nd ed.). Guilford Press. Loevinger, J. (1997). Stages of personality development. In R. Hogan, J. A. Johnson, & S. R. Briggs (Eds.), Handbook of personality psychology (pp. 199–208). Academic Press. https://doi.org/10.1016/B978-012134645-4/50009-3 Lowell, A., Lopez-Yianilos, A., & Markowitz, J. (2020). Interpersonal psychotherapy. In J. Ford & C. Courtois (Eds.), Treating complex traumatic stress disorders in adults (pp. 350–369). Guilford Press. Macaulay, C. B., & Angus, L. E. (2019). The narrative-emotion process model: An integrative approach to working with complex posttraumatic stress. Journal of Psychotherapy Integration, 29(1), 42–53. https://doi.org/10.1037/int0000118 Madigan, S. (2019). Narrative therapy (2nd ed.). American Psychological Association. https://doi.org/10.1037/0000131-000 Main, M. (1991). Metacognitive knowledge, metacognitive monitoring, and singular (coherent) vs. multiple (incoherent) model of attachment: Findings and directions for future research. In C. M. Parkes, J. Stevenson-Hinde, & P. Marris (Eds.), Attachment across the life cycle (pp. 127–159). Tavistock/Routledge. Main, M., & Goldwyn, R. (1984). Predicting rejection of her infant from mother. Child Abuse & Neglect, 8(2), 203–217. https://doi.org/10.1016/0145-2134(84)90009-7 Marks, E. H., Walker, R. S. W., Ojalehto, H., Bedard-Gilligan, M. A., & Zoellner, L. A. (2019). Affect labeling to facilitate inhibitory learning: Clinical considerations. Cognitive and Behavioral Practice, 26(1), 201–213. https://doi.org/10.1016/ j.cbpra.2018.05.001

References 343

McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolfe, J., & Hurley, C. L. (2003). Treating affect phobia: A manual for short term dynamic psychotherapy. Guilford Press. Meneses, C. W., & Greenberg, L. S. (2011). The construction of a model of the process of couples’ forgiveness in emotion-focused therapy for couples. Journal of Marital and Family Therapy, 37(4), 491–502. https://doi.org/10.1111/j.1752-0606. 2011.00234.x Mikaeili, N., Molavi, P., Einy, S., & Tagaery, R. (2017). Effectiveness of emotionfocused therapy on emotion dysregulation, hopelessness, and suicidal ideation in posttraumatic stress veterans. Iranian Journal of War and Public Health, 9(3), 111–117. https://doi.org/10.18869/acadpub.ijwph.9.3.111 Miller, R. (2015). The iRest program for healing PTSD: A proven-effective approach to using yoga nidra meditation and deep relaxation techniques to overcome trauma. New Harbinger Publications. Mlotek, A. E. (2019). Contributions of emotional competence to the link between childhood maltreatment and adult attachment [Unpublished doctoral dissertation]. University of Windsor. Moody, G., Cannings-John, R., Hood, K., Kemp, A., & Robling, M. (2018). Establishing the international prevalence of self-reported child maltreatment: A systematic review by maltreatment type and gender. BMC Public Health, 18(1), 1164. https:// doi.org/10.1186/s12889-018-6044-y Morgan, T., & Cummings, S. L. (1999). Change experienced during group therapy by female survivors of childhood sexual abuse. Journal of Consulting and Clinical Psychology, 67(1), 28–36. https://doi.org/10.1037/0022-006X.67.1.28 Mundorf, E. S. (2013). Childhood abuse survivors’ experiences of self over the course of emotion-focused therapy for trauma: A qualitative analysis [Unpublished doctoral dissertation]. University of Windsor. Mundorf, E. S., & Paivio, S. C. (2011). Narrative quality and disturbance pre- and post-emotion-focused therapy for child abuse trauma. Journal of Traumatic Stress, 24(6), 643–650. https://doi.org/10.1002/jts.20707 Muntigl, P., Horvath, A. O., Chubak, L., & Angus, L. (2020). Getting to “yes”: Overcoming client reluctance to engage in chair work. Frontiers in Psychology, 11, Article 582856. https://doi.org/10.3389/fpsyg.2020.582856 Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. Guilford Press.

Neimeyer, R. A. (2006). Complicated grief and the reconstruction of meaning: Conceptual and empirical contributions to a cognitive-constructivist model. Clinical Psychology: Science and Practice, 13(2), 141–145. https://doi.org/10.1111/ j.1468-2850.2006.00016.x Neimeyer, R. A. (Ed.). (2016). Techniques of grief therapy: Assessment and intervention. Routledge/Taylor & Francis Group. Neimeyer, R. A., & Sands, D. C. (2015). Containing the story of violent death. In R. A. Neimeyer (Ed.), Techniques of grief therapy (pp. 330–335). Routledge. Neria, Y. (2021). Functional neuroimaging in PTSD: From discovery of underlying mechanisms to addressing diagnostic heterogeneity. The American Journal of Psychiatry, 178(2), 128–135. https://doi.org/10.1176/appi.ajp.2020.20121727 Novaco, R. W. (2007). Anger dysregulation. In T. A. Cavell & K. T. Malcolm (Eds.), Anger, aggression, and interventions for interpersonal violence (pp. 3–54). Erlbaum. Novaco, R. W., & Chemtob, C. M. (2015). Violence associated with combat-related posttraumatic stress disorder: The importance of anger. Psychological Trauma: Theory, Research, Practice, and Policy, 7(5), 485–492. https://doi.org/10.1037/tra0000067

344  References

Ogden, P., & Fisher, J. (2015). Sensorimotor psychotherapy: Interventions for trauma and attachment. Norton. Ogrodniczuk, J. S., Joyce, A. S., & Abbass, A. A. (2014). Childhood maltreatment and somatic complaints among adult psychiatric outpatients: Exploring the mediating role of alexithymia. Psychotherapy and Psychosomatics, 83(5), 322–324. https://doi.org/10.1159/000363769 O’Kearney, R., & Perrott, K. (2006). Trauma narratives in posttraumatic stress disorder: A review. Journal of Traumatic Stress, 19(1), 81–93. https://doi.org/10.1002/ jts.20099 O’Malley, S. S., Suh, C. S., & Strupp, H. H. (1983). The Vanderbilt Psychotherapy Process Scale: A report on the scale development and a process-outcome study. Journal of Consulting and Clinical Psychology, 51(4), 581–586. https://doi.org/ 10.1037/0022-006X.51.4.581 Paivio, S. C. (Therapist). (2013). Emotion-focused therapy for trauma [Film; educational DVD]. American Psychological Association. https://www.apa.org/pubs/ videos/4310912.aspx Paivio, S. C. (Therapist). (2015). Emotion-focused therapy with a middle-aged woman suffering from depression [Film; educational DVD]. American Psychological Association. Paivio, S. C. (Therapist). (2016). Emotion-focused therapy with empty-chair technique [Film; educational DVD]. American Psychological Association. Paivio, S. C., & Angus, L. E. (2017). Narrative processes in emotion-focused therapy for trauma. American Psychological Association. https://doi.org/10.1037/0000041-000 Paivio, S. C., & Bahr, L. (1998). Interpersonal problems, working alliance, and outcome in short-term experiential therapy. Psychotherapy Research, 8(4), 392–407. https://doi.org/10.1080/10503309812331332487 Paivio, S. C., & Carriere, M. (2007). Contributions of emotion-focused therapy to the understanding and treatment of anger and aggression. In T. A. Cavell & T. Malcolm (Eds.), Anger, aggression, and interventions for interpersonal violence (pp. 143–164). Erlbaum. Paivio, S. C., & Greenberg, L. S. (1995). Resolving “unfinished business”: Efficacy of experiential therapy using empty-chair dialogue. Journal of Consulting and Clinical Psychology, 63(3), 419–425. https://doi.org/10.1037/0022-006X.63.3.419 Paivio, S. C., Hall, I. E., Holowaty, K. A. M., Jellis, J. B., & Tran, N. (2001). Imaginal confrontation for resolving child abuse issues. Psychotherapy Research, 11(4), 433–453. https://doi.org/10.1093/ptr/11.4.433 Paivio, S. C., Holowaty, K. A. M., & Hall, I. E. (2004). The influence of therapist adherence and competence on client reprocessing of child abuse memories. Psychotherapy: Theory, Research, & Practice, 41(1), 56–68. https://doi.org/10.1037/ 0033-3204.41.1.56 Paivio, S. C., Jarry, J. L., Chagigiorgis, H., Hall, I., & Ralston, M. (2010). Efficacy of two versions of emotion-focused therapy for resolving child abuse trauma. Psycho­ therapy Research, 20(3), 353–366. https://doi.org/10.1080/10503300903505274 Paivio, S. C., & Kuo, B. (2007). New application of EFTT: Refugee trauma [Paper presentation]. Society for the Exploration of Psychotherapy Integration Meeting, Lisbon, Portugal. Paivio, S. C., & Laurent, C. (2001). Empathy and emotion regulation: Reprocessing memories of childhood abuse. Journal of Clinical Psychology, 57(2), 213–226. https://doi.org/10.1002/1097-4679(200102)57:23.0.CO;2-B

References 345

Paivio, S. C., & McCulloch, C. R. (2004). Alexithymia as a mediator between childhood trauma and self-injurious behaviors. Child Abuse & Neglect, 28(3), 339–354. https://doi.org/10.1016/j.chiabu.2003.11.018 Paivio, S. C., & Nieuwenhuis, J. A. (2001). Efficacy of emotion focused therapy for adult survivors of child abuse: A preliminary study. Journal of Traumatic Stress, 14(1), 115–133. https://doi.org/10.1023/A:1007891716593 Paivio, S. C., & Shimp, L. N. (1998). Affective change processes in therapy for PTSD stemming from childhood abuse. Journal of Psychotherapy Integration, 8(4), 211–229. Pascual-Leone, A. (2009). Dynamic emotional processing in experiential therapy: Two steps forward, one step backward. Journal of Consulting and Clinical Psychology, 77, 113–126. https://doi.org/10.1037/a0014488 Pascual-Leone, A. (2018). How clients “change emotion with emotion”: A programme of research on emotional processing. Psychotherapy Research, 28(2), 165–182. https://doi.org/10.1080/10503307.2017.1349350 Pascual-Leone, A., Gillis, P., Singh, T., & Andreescu, C. (2013). Problem anger in psychotherapy: An emotion-focused perspective on hate, rage, and rejecting anger. Journal of Contemporary Psychotherapy, 43(2), 83–92. https://doi.org/ 10.1007/s10879-012-9214-8 Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional processing in experiential therapy: Why “the only way out is through.” Journal of Consulting and Clinical Psychology, 75(6), 875–887. https://doi.org/10.1037/0022-006X.75.6.875 Pascual-Leone, A., & Greenberg, L. S. (2020). Emotion focused therapy: Integrating neuroscience into practice. In R. D. Lane & L. Nadal (Eds.), Neuroscience of enduring change: Implications for psychotherapy (pp. 215–244). Oxford University Books. https://doi.org/10.1093/oso/9780190881511.003.0009 Pascual-Leone, A., Kim, J., & Morrison, O. P. (2017). Working with victims of human trafficking. Journal of Contemporary Psychotherapy, 47(1), 51–59. https:// doi.org/10.1007/s10879-016-9338-3 Pascual-Leone, A., & Kramer, U. (2019). How clients “change emotion with emotions”: Sequences in emotional processing and their clinical implications. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 147–170). American Psychological Association. https://doi.org/ 10.1037/0000112-007 Pascual-Leone, A., Paivio, S., & Harrington, S. (2016). Emotion in psychotherapy: An experiential-humanistic perspective. In D. J. Cain, S. Rubin, & K. Keenan (Eds.), Humanistic psychotherapies: Handbook of research and practice (2nd ed., pp. 147–181). American Psychological Association. https://doi.org/10.1037/14775-006 Pascual-Leone, A., & Yeryomenko, N. (2017). The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process. Psychotherapy Research, 27(6), 653–665. https://doi.org/10.1080/10503307.2016.1152409 Pascual-Leone, A., Yeryomenko, N., Morrison, O.-P., Arnold, R., & Kramer, U. (2016). Does feeling bad, lead to feeling good? Arousal patterns during expressive writing. Review of General Psychology, 20(3), 336–347. https://doi.org/10.1037/ gpr0000083 Patihis, L., & Pendergrast, M. H. (2019). Reports of recovered memories of abuse in therapy in a large age-representative U.S. national sample: Therapy type and decade comparisons. Clinical Psychological Science, 7(1), 3–21. https://doi.org/ 10.1177/2167702618773315

346  References

Pearlman, L. A., Caringi, J., & Trautman, A. R. (2020). New perspectives on vicarious traumatization and complex trauma. In J. D. Ford & C. A. Courtois (Eds.), Treating complex traumatic stress disorders in adults (2nd ed., pp. 189–206). Guilford Press. Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472. https://doi.org/10.1037/pst0000165 Pennebaker, J. W., & Chung, C. K. (2011). Expressive writing: Connections to physical and mental health. In H. S. Friedman (Ed.), Oxford handbook of health psychology (pp. 417–437). Oxford University Press. https://doi.org/10.1093/ oxfordhb/9780195342819.013.0018 Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy. Julian Press. Pessoa, L. (2013). The cognitive-emotional brain: From interactions to integration. MIT Press. https://doi.org/10.7551/mitpress/9780262019569.001.0001 Polaris. (2020). Analysis of 2020 National Human Trafficking Hotline data. https:// polarisproject.org/2020-us-national-human-trafficking-hotline-statistics/ Pollak, S. D., & Sinha, P. (2002). Effects of early experience on children’s recognition of facial displays of emotion. Developmental Psychology, 38(5), 784–791. https:// doi.org/10.1037/0012-1649.38.5.784 Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation. Norton. Porges, S. W., & Dana, D. A. (2018). Clinical applications of the polyvagal theory: The emergence of polyvagal-informed therapies. Norton. Pos, A. E., & Choi, B. H. (2019). Relating process to outcome in emotion-focused therapy. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotionfocused therapy (pp. 171–191). American Psychological Association. https://doi. org/10.1037/0000112-008 Pos, A. E., Greenberg, L. S., & Warwar, S. H. (2009). Testing a model of change in the experiential treatment of depression. Journal of Consulting and Clinical Psychology, 77(6), 1055–1066. https://doi.org/10.1037/a0017059 Pos, A. E., & Paolone, D. A. (2019). Emotion-focused therapy for personality disorders. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 381–402). American Psychological Association. https://doi.org/ 10.1037/0000112-017 Power, M. J., & Fyvie, C. (2013). The role of emotion in PTSD: Two preliminary studies. Behavioural and Cognitive Psychotherapy, 41(2), 162–172. https://doi.org/ 10.1017/S1352465812000148 Pugh, M., Bell, T., & Dixon, A. (2021). Delivering tele-chairwork: A qualitative survey of expert therapists. Psychotherapy Research, 31(7), 843–858. https://doi.org/ 10.1080/10503307.2020.1854486 Ralston, M. (2006). Emotional arousal and depth of experiencing in imaginal confrontation versus evocative empathy [Unpublished doctoral dissertation]. University of Windsor. Reinhardt, K. M., Noggle Taylor, J. J., Johnston, J., Zameer, A., Cheema, S., & Khalsa, S. B. S. (2018). Kripalu yoga for military veterans with PTSD: A random­ ized trial. Journal of Clinical Psychology, 74(1), 93–108. https://doi.org/10.1002/ jclp.22483 Resick, P. A., Nishith, P., & Griffin, M. G. (2003). How well does cognitive-behavioral therapy treat symptoms of complex PTSD? An examination of child abuse

References 347

survivors within a clinical trial. CNS Spectrums, 8(5), 340–355. https://doi.org/ 10.1017/S1092852900018605 Robinson, K. J. P. (2021). Yoga for anxiety and trauma. https://www.katlin.robinson.com Rogers, C. R. (1980). A way of being. Houghton-Mifflin. Rudkin, A., Llewelyn, S., Hardy, G., Stiles, W. B., & Barkham, M. (2007). Therapist and client processes affecting assimilation and outcome in brief psychotherapy. Psychotherapy Research, 17(5), 613–621. https://doi.org/10.1080/10503300701216298 Safran, J. D., & Greenberg, L. S. (1987). Emotion in psychotherapy: Affect, cognition, and the process of change. Guilford Press. Salgado, J., Cunha, C., & Monteiro, M. (2019). Emotion-focused therapy for depression. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 293–314). American Psychological Association. https://doi.org/10.1037/0000112-013 Sareen, J. (2018). Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. UpToDate. https://medilib.ir/uptodate/show/500 Saxe, B. J., & Johnson, S. M. (1999). An empirical investigation of group treatment for a clinical population of adult female incest survivors. Journal of Child Sexual Abuse, 8(1), 67–88. https://doi.org/10.1300/J070v08n01_05 Schore, A. (2003). Affect dysregulation and disorders of the self. Norton. Schore, A. N. (2019). Right brain psychotherapy. Norton. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse (2nd ed.). Guilford Press. Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures (3rd ed.). Guilford Press. Simon, N. M., Hofmann, S. G., Rosenfield, D., Hoeppner, S. S., Hoge, E. A., Bui, E., & Khalsa, S. B. S. (2021). Efficacy of yoga vs cognitive behavioral therapy vs stress education for the treatment of generalized anxiety disorder: A randomized clinical trial. JAMA Psychiatry, 78(1), 13–20. https://doi.org/10.1001/ jamapsychiatry.2020.2496 Smith, S. F., & Ford, J. D. (2020). Complementary healing therapies. In J. D. Ford & C. A. Courtois (Eds.), Treating complex traumatic stress disorders in adults (pp. 569–590). Guilford Press. Stover, C. S., Ippen, C. G., Liang, L.-J., Briggs, E. C., & Berkowitz, S. J. (2019). An examination of partner violence, polyexposure, and mental health functioning in a sample of clinically referred youth. Psychology of Violence, 9(3), 359–369. https://doi.org/10.1037/vio0000131 Sturmey, P. (2017). The Wiley handbook of violence and aggression. Wiley-Blackwell. https://doi.org/10.1002/9781119057574 Taillieu, T. L., Brownridge, D. A., Sareen, J., & Afifi, T. O. (2016). Childhood emotional maltreatment and mental disorders: Results from a nationally representative adult sample from the United States Applied Health Sciences PhD Program. Child Abuse & Neglect, 59, 1–12. https://doi.org/10.1016/j.chiabu.2016.07.005 Taylor, G. J., Bagby, R. M., & Parker, J. D. A. (1997). Disorders of affect regulation: Alexithymia in medical and psychiatric illness. Cambridge University Press. https:// doi.org/10.1017/CBO9780511526831 Tedeschi, R., Shakespeare-Finch, J., Taku, K., & Calhoun, L. G. (2018). Posttraumatic growth: Theory, research, and applications. Routledge. https://doi.org/10.4324/ 9781315527451

348  References

United Nations High Commissioner for Refugees. (2020). Global trends: Forced displacement in 2019. https://www.unhcr.org/5ee200e37.pdf Vaillant, G. E. (1994). Ego mechanisms of defense and personality psychopathology. Journal of Abnormal Psychology, 103(1), 44–50. https://doi.org/10.1037/0021-843X. 103.1.44 van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking. van der Kolk, B. A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books. van der Kolk, B. A. (2020). Afterword. In J. D. Ford & C. A. Courtois (Eds.), Treating complex traumatic stress disorders in adults (2nd ed., pp. 603–615). Guilford Press. van der Kolk, B. A., & McFarlane, A. C. (1996). The black hole of trauma. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 3–23). Guilford Press. van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M., & Spinazzola, J. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: A randomized controlled trial. The Journal of Clinical Psychiatry, 75(6), e559–e565. https://doi.org/10.4088/JCP.13m08561 Watson, J. (2019). Role of the therapeutic relationship in emotion-focused therapy. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 111–128). American Psychological Association. https://doi.org/ 10.1037/0000112-005 Watson, J., Timulak, L., & Greenberg, L. S. (2019). Emotion focused therapy for generalized anxiety disorder. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotion-focused therapy (pp. 315–336). American Psychological Association. https://doi.org/10.1037/0000112-014 Watson, J. C., & Greenberg, L. S. (2017). Emotion-focused therapy for generalized anxiety disorder. American Psychological Association. https://doi.org/10.1037/ 0000018-000 Watson, J. C., McMullen, E. J., Prosser, M. C., & Bedard, D. L. (2011). An examination of the relationships among clients’ affect regulation, in-session emotional processing, the working alliance, and outcome. Psychotherapy Research, 21(1), 86–96. https://doi.org/10.1080/10503307.2010.518637 Weintraub, A. (2003). Yoga for depression: A compassionate guide to relieve suffering through yoga. Harmony. Weissman, N., Batten, S., Rheem, K., Wiebe, S., Pasillas, R., Potts, W., Barone, M., Brown, C., & Dixon, L. (2017). The effectiveness of emotionally focused couples therapy with veterans with PTSD: A pilot study. Journal of Couple & Relationship Therapy, 17(1), 25–41. https://doi.org/10.1080/15332691.2017.1285261 Whelton, W. J., & Greenberg, L. S. (2005). Emotion in self-criticism. Personality and Individual Differences, 38(7), 1583–1595. https://doi.org/10.1016/j.paid.2004.09.024 Wilker, S., Pfeiffer, A., Kolassa, S., Koslowski, D., Elbert, T., & Kolassa, I. T. (2015). How to quantify exposure to traumatic stress? Reliability and predictive validity of measures for cumulative trauma exposure in a post-conflict population. European Journal of Psychotraumatology, 6(1), Article 28306. https://doi.org/ 10.3402/ejpt.v6.28306 Winnicott, D. W. (1965). The maturational processes and the facilitating environment. International University Press.

References 349

Woldarsky Meneses, C., & McKinnon, J. M. (2019). Emotion focused therapy for couples. In L. S. Greenberg & R. N. Goldman (Eds.), Clinical handbook of emotionfocused therapy (pp. 447–469). American Psychological Association. https:// doi.org/10.1037/0000112-020 Wolfe, D. A. (2007). Understanding anger: Key concepts from the field of domestic violence and child abuse. In T. Cavell & K. Malcolm (Eds.), Anger, aggression, and interpersonal violence (pp. 393–402). Erlbaum. World Health Organization. (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/ Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: Putative role of epigenetic mechanisms. World Psychiatry, 17(3), 243–257. https:// doi.org/10.1002/wps.20568

INDEX

A AAI (Adult Attachment Interview), 27, 155 Abandonment, 185–186, 208 Abuse, severity of, 97. See also specific types Accelerated experiential dynamic psychotherapy (AEDP), 105–106, 182, 209 Acceptance and allowing painful emotions, 193–194 in compassionate self-soothing, 231 facilitating genuine, 271 of hopeless situation, 188 of limited change, 285–287 of losses, 258, 265, 274–276 of perpetrator, 34–35 and pseudoresolution, 286–287 in structured focusing procedure, 117–118 unconditional, 83 in yoga therapy, 315 Acceptance and commitment therapy, 182, 308 Acknowledgement, 123 Adaptive anger, 241–242 benefits of, 38, 239–240 changing maladaptive anger to, 246–248 distinguishing, from other types of anger, 240–243 and fear, shame, self-blame, 141 intervention for promoting, 248–256 in memory work, 176 primary, 241, 248–256 principles for working with, 243–246

resolution of trauma through, 46, 235–256 theoretical perspectives on trauma and, 238–240 in transformation of shame, 212–213 validating experience of, 247 Adaptive anxiety, 183–184 Adaptive emotions, 59–60, 63 body-based interventions to access, 326–327 differentiating, 53 emotion awareness training on, 88 focusing on, 38 global distress with underlying, 61 in memory work, 163 modifying maladaptive emotions with, 7–8, 60 reflection on, 69 secondary emotions covering, 191–192 Adaptive experiences, to reduce shame, 214–215 Adaptive fear, 183 Adaptive functioning, emotion in, 56–57 Adaptive guilt, 211 Adaptive hopelessness, 188 Adaptive resources, memory work to access, 159 Adaptive sadness, 212–213, 257, 261–262, 266–268 Adaptive shame, 210, 217–218 Adherence, outcome and, 109 Adhi mudras, 318  351

352  Index

Adjunct treatments, 23, 295 Adult Attachment Interview (AAI), 27, 155 Adult self-protective resources, 160, 163, 174, 175, 228 AEDP. See Accelerated experiential dynamic psychotherapy Affect, 38, 221, 243 Affective neuroscience, 296 Affect phobia therapy, 182 Affect regulation, 5, 6, 27, 28, 42, 44 Agency. See Personal agency Aggression, 28, 30, 238, 243, 247 Alcoholics Anonymous, 188 Alexithymia awareness and arousal for clients with, 65 deepening experiencing for clients with, 111 as effect of trauma, 27, 29 EFTT and yoga therapy for treatment of, 307 emotion awareness training for clients with, 89 empathic responding for clients with, 51, 52 experiencing tasks for clients with, 43 PTSD/CPTSD with, 5 Alienation, 23, 52, 274 Alliance. See Therapeutic alliance Allowing phase (model of allowing emotional pain), 193–194 Alternative behaviors, 252 Ambivalence, about seeking treatment, 95 American Psychiatric Association, 16, 18, 22–24, 37 American Psychological Association (APA), 4, 41 Anger, 3. See also Adaptive anger about termination, 292 assertive, 75, 176, 239–242, 244, 252 complexity of processes related to, 243 defensive, 239, 244 difficulties letting go of, 290–291 distinguishing between types of, 6, 240–243 as dominant emotion with PTSD, 16 exploring, in final dialogue, 280–281 expressing, in IC, 140–143 fear of, 239 healthy expression of, 241–242 instrumental, 62, 243, 246 at interpersonal violation, 59, 241, 267 maladaptive, 242, 246–248 promoting primary sadness over, 268–269 rejecting, 74, 287, 314 resolution through sadness vs., 250–251 sadness secondary to, 263 secondary, 242–243, 245–248

secondary emotions about feeling, 61 self-directed, 212 strengthening self with, 267 theoretical perspectives on trauma and, 238–240 Anger control problems adaptive emotions covered by, 192 childhood physical abuse and, 30 with PTSD, 23, 31 resolution for clients with, 252 as target of therapy, 240 for trauma survivors, 238–239 unresolved trauma and, 28 Anger cues, sensitivity to, 26, 36 Angus, L., 9, 93, 119, 156 Anhedonia, 263 Anniversary reactions, 260 Anxiety. See also Shame–anxiety about external situations, 204–205 about therapy, 43, 95 adaptive, 183–184 change processes/goals for addressing, 186–189 distinguishing between types of, 183–186 in EFTT vs. other approaches, 35, 182–183 empathic responding to reduce, 81 and experiential avoidance, 181 focus on emotional processes for clients with, 101 interventions for managing, 189–192 problematic, 184–185 PTSD and, 16, 23 reassurance to reduce, 85 secondary emotions with, 61 shame–anxiety, 87, 208, 211–212, 327–329 and structured focusing procedure, 117 tasks for resolving, 197 validation to reduce, 81, 82 yoga therapy to address, 307, 311 Anxiety disorders, 24, 37 APA (American Psychological Association), 4, 41 Apology, 254–255, 281, 290–291 Appraisal, reflection to change, 69–70 Approaching phase (model of allowing emotional pain), 193 Appropriate expression, of emotion, 28, 57, 60, 63, 251 Approval seeking, 254, 255 Arousal and reactivity symptoms, of PTSD, 22, 28 Arousal stage (IC procedure), 139–142 Asanas, 309–310, 316–321 Assertive expression of emotion anger, 75, 176, 239–242, 244, 252 body-based interventions to promote, 313



Index 353

maintaining gains in, 281–282 and need, 254 reintroducing IC at, 148–149 sadness, 141, 262 Assertiveness training, 239, 252 Associative network, 56–57 Attachment, 31, 35–36, 86, 88, 289 Attachment-based psychodynamic approach, 35, 182 Attachment bond, 79 difficulties establishing, 100–101 empathic responding to strengthen, 99 establishing secure, 86–87 during IC procedure, 143–144 positive emotions for, 60 Attachment figures compassionate soothing from, 226 desire for connection with, 270 differentiated perspective of, 47 as focus of EFTT, 40–41 forgiveness for, 237 grieving lack of love from, 271 imaginal confrontation with, 127. See also imagined other ongoing relationships with, 286 resolving issues with, 4 Attachment injuries, 39–40, 46–47, 53, 260, 268–269 Attachment style, sense of self and, 92. See also specific types Attachment theory, 25, 26, 40, 57–58, 105–106 Authentic expression, 203–204 Autobiographical memory access to, 164 evoking, 47, 48, 215 trauma as disruptor of, 25–26 trauma narratives lacking, 155 Avoidance of internal experience (experiential avoidance) of adaptive anger, 241 beginning to address, 89 and change processes of EFTT, 62–63, 186–189 with conscious and deliberate suppression, 192 defined, 190–191 due to fear/anxiety, 181 effects of, 28–29, 43 EFTT treatment model for reducing, 44, 46 in EFTT vs. other approaches, 182–183 and emotional competence, 27–29 experiencing tasks to reduce, 43 in general model of EFT, 8 goals for addressing, 186–189 helping clients address, 192–205 in IC procedure, 144 markers of, 94

in memory work, 162 of painful emotions, 59–60, 63 of primary adaptive emotions, 59–60, 241 providing information on, 83 with PTSD, 5, 8, 22, 28, 185 with secondary emotions, 191–192 of shame, 213 in structured focusing procedure, 117 theory of dysfunction specific to trauma on, 36 types of, 190–192 unintentional reinforcement of, 101 Avoidant personality disorder, 137, 208, 219 Awareness. See also Present-centered awareness of bodily experience, 87, 88, 111, 307, 311–312, 316 of changes in internal processes, 284–285 of intrapersonal conflict, 196–197 of limited change at termination, 285–287 of losses and associated needs, 265 of personal agency, 189 of positive change, 284–285 self-, 50–51, 69–70 of victimization/powerlessness, 254 Awareness of emotional experience (emotion awareness), 5, 64–67 to address instrumental anger, 246 to address secondary anger, 247 and attachment, 88 and capacity for experiencing, 105 for clients with alexithymia, 65 directing client to attend, 47–49 in EFTT, 64–67 EFTT for clients lacking, 35 emotional neglect and, 31 empathic responding to increase, 50–51, 81 experiencing as foundation for, 123–124 identifying difficulties with, 93 for resolution of intrapersonal conflict, 199–200 for resolution of self-criticism, 221 in sequential model of emotional processing, 73 yoga therapy and EFTT to improve, 307 yoga therapy to increase, 311–312 B Bad feelings agency and contributing to, 54, 214 allowing, in EFTT, 264 changing, as goal of therapy, 55 complex, 6, 28, 61–63, 185–186 exploring, in EFTT, 62–63

354  Index

“bad object” view of imagined other, 92, 132, 236, 291 Balancing breath work, 315, 316 Behavioral approach, 7, 35, 37, 106, 209 Behavioral avoidance, 189 Behavioral self-soothing, 227 Beliefs, 89, 169–170, 183, 196–197 Bellows breath, 316 Belly breathing, 316 Betrayal, 261–262 Bhu mudra, 317–318 Bodily experience attending to, 101, 111, 115, 160, 316 awareness of, 87, 88, 111, 307, 311–312, 316 labeling, 314 in resolution of intrapersonal conflict, 199–200 Body-based interventions, 10, 297. See also Yoga therapy background literature on, 310 effectiveness of, 310–311 general guidelines for, 317–320 over course of EFTT, 323–331 rationale for, 324–325 Bolger, E. A., 195 Booster sessions, 279, 294 Borderline personality disorder, 82, 137, 182, 208, 239, 243 Bottom-up processing, 39, 49, 115, 200, 225–226 Boundary definition, maintaining gains in, 281–282 Bowlby, J., 86 Breath, attention to, 315–316 Breathing exercises, 114, 308 Bridging to future, 143, 224, 227, 294, 331 Bridging to present (bridging to life), 118–119, 229 Buddhism, 188, 308, 309 C Callahan, J. L., 155 Calming, 114–115, 313, 317–318 Carriere, M., 240 Case conceptualization, 9, 45, 90–94 core maladaptive emotion scheme for, 91–93 dimensions of, 90 dominant emotion processing difficulties for, 93 implications of, for therapy, 94 and initial dialogue in IC, 129 refining, during IC procedure, 144–145 tailoring, to client, 97 task markers for, 94 Catastrophic expectations, 61, 196, 200, 204–205

CBT. See Cognitive behavior therapy Celebrating change, 285 Central concern, identifying, 51, 81 Change general model of, 185, 186, 238 theory of, 37–38 Change(s) common factors, 104–105, 156 consolidation of, 282–285 in internal processes, 284–285 promotion of, 83 as pseudoresolution, 286–287 Change narratives, 156, 284 Change processes, 62–75 for addressing anxiety, 186–189 for addressing experiential avoidance, 186–189 for addressing fear, 186–189 and consolidation of change, 280–285 for deepening experiencing, 109–113 for downregulating intensity, 64, 67, 69 in EFTT with yoga therapy, 311–314 emotional awareness and arousal, 64–67 emotional transformation, 64, 70–72, 212–213 imaginal confrontation and, 125–127, 132–137 in memory work, 158–160 and phases of EFTT, 72–75 reflection on emotion, 64, 69–70 for resolution through sadness and grief, 264–266 therapeutic relationship and emotional processing as, 6–8 for transforming shame, 212–213 Childhood adversity, disturbances related to, 20–21 Childhood maltreatment (abuse and neglect), 3–4 anger response of survivors of, 238 avoidance for survivors of, 191 and borderline personality disorder, 82 developmental effects of, 17 differentiated perspective of perpetrators of, 47 effects of, 30–31 EFTT for clients with history of, 4–5, 33–35, 41 emotional competence deficits and, 28–29 empathic responding for survivors of, 49–50 environmental invalidation with, 174 forgiveness for perpetrators of, 237 interpersonal problems with perpetrators of, 128–129 losses associated with, 258 maternal depression and, 27 memory work for survivors of, 169–170



Index 355

prevalence of, 19–20, 295 primary adaptive shame for survivors of, 210 resolution of trauma related to, 132, 240, 283 right brain development and, 27 self-related problems for survivors of, 25 severity of, 42 theory of dysfunction specific to trauma in, 36 trauma-focused therapy with survivors of, 85–86 Childhood trauma difficulties with experiencing for clients with histories of, 120–121 EFFT for clients with history of, 6 narratives of attachment experiences with unresolved, 155–156 parenting difficulties and unresolved, 26–27 reexperiencing memories of, 156–158 Child sexual abuse, 17, 19, 30, 42, 208–209 Child’s pose, 318 Chinmaya mudra, 318 Circular breathing, 316 Clarity about IC task, 150 about trauma reactions, 164, 168–170 focusing to improve, 119–120 of target of healthy anger, 241 Classical conditioning, 21 Client defining role of, 83–84 EFTT perspective on experience of, 105 eliciting theories from, 95 mutual feedback between therapist and, 287–289 suitability of, for EFTT, 6, 279 Client-centered therapies, 100–101, 108–109 Client experiencing, 106. See also Experiencing Client Experiencing Scale, 107, 299 Closure, 280–282 Cognitive behavior therapy (CBT), 35, 37 challenging beliefs in, 183 for complicated grief, 259 emotional processing in, 63–64 emotion regulation in, 67 experiencing in, 106, 108–109 fear of anger in, 239 maladaptive beliefs in, 197 reducing shame with, 209 self-criticism interventions in, 225 structured focusing procedure in, 114 Cognitive goals, 56 Cognitively-oriented clients, 101 Cognitive processes, 22–23, 37, 60–62 Cognitive restructuring, 259

Cognitive therapy, 7, 106, 182, 200, 209, 308 Coherence, 174 Collaboration, 45 on case conceptualization, 90–94, 144–145 on memory work, 161 to overcome difficulties with two-chair dialogues, 231 on termination of therapy, 279 for therapeutic alliance, 79–80 in yoga therapy, 311, 321 Combat-related trauma, 17–19, 26, 297 Common change factors, 104–105, 156 Communication, 57, 80, 84–87, 210, 245 Communication skills, 25, 52 Compassion, 45 and adaptive shame, 218 body-based interventions to promote, 319 for client’s painful emotions, 193, 267 defined, 80 establishing attachment bond with, 86–87 for imagined other, 255–256, 272–274 self-, 60, 260, 329–330 and therapeutic alliance, 79, 80, 86–87 in yoga therapy, 314 Compassionate self-soothing, 225–231 Compassion-based meditation, 323 Compassion-focused therapy, 209 Competing plotlines, storytelling with, 192 Complementary treatments, 295, 305 Complex “bad feelings,” 6, 28, 61–63, 185–186 Complex posttraumatic stress disorder (CPTSD) adaptive shame for clients with, 217 catastrophic expectations with, 204 dysfunctional beliefs in, 183 fear, anxiety, and avoidance in, 182 guilt, shame, and self-blame in, 208 support for EFTT as treatment for, 297 symptoms of, 24–25 yoga therapy for clients with, 314 Complex trauma, 4 adaptive guilt and, 211 assessment with survivors of, 97 awareness and arousal for survivors of, 65 childhood maltreatment and, 3–4, 19–20 described, 3 disturbances linked to, 296–297 emotional competence deficits and, 36 emotional engagement with, 297–298 emotional processing of, 37–38, 55, 64 emotion regulation in therapy for, 67 global distress for survivors of, 73 hope in therapy for, 84

356  Index

interpersonal problems and, 236 meditation for survivors of, 323 mindfulness treatment for, 107 narrative disclosure therapy for, 157–158 nervous system dysregulation with, 22 prevalence of, 18–19 primary emotions of survivors of, 59, 60, 219 process map for treatment of, 74 prolonged exposure for survivors of, 157 relationships with perpetrators of, 273–274 resolution of, 134–135, 201, 283–284 sadness associated with, 264 self-organization and, 58 self-related losses in, 274 single incident/limited exposure trauma vs., 17 validation for survivors of, 123 Complicated grief, 258–260, 263 Concerns, focusing on, 111 Concrete memories, 131, 150, 165 Confidence, 137, 286, 289, 324 Confrontation, in EFTT, 44 Confrontation ruptures, 99, 100 Confusion, 150, 164, 168–170 Conjecture, 51, 81, 122–123 Connectedness, interpersonal, 52–53, 81, 86, 236, 274–275, 315 Connotative language, 131 Conscious avoidance, 191–205 Consistency, in promotion of experiencing, 121 Consolidation of change, 280–285 Constructivism, 58, 106 Contact, psychological, 53, 135, 136, 147, 269 Contempt, 212, 219, 243, 270 Continuation of services, 279, 293 Control, 28–29, 89, 192–205, 208, 217–218, 241, 314 “Cool” learning, 187 Coping, capacity for, 260 Core adaptive emotions, 88 Core emotional processes, IC and, 129, 131–132 Core emotion scheme, 54, 91–93, 159, 164–165, 178 Core maladaptive beliefs, 169–170 Core maladaptive emotions, 88 Core memories, defective/damaged, 173–177 Core negative self-evaluation, 91–93 Core sense of self and attachment style, 92 awareness and arousal work with emotions central to, 66–67 compassionate self-soothing for, 227 damaged or defective, 175–177 maladaptive emotion and, 60, 61, 63

memory work to activate, 47, 162–163 restructuring, 181 shame-based, 219 vulnerable or insecure, 184–185 Core unmet needs, 92–93 “Correct” assertive communication, 245 CPTSD. See Complex posttraumatic stress disorder Crime, as traumatic event, 16 Crocodile tears, 62 Crying, 261, 263, 268, 269 Cultural norms, 110, 178, 210, 245 Cumulative trauma, PTSD risk and, 20 Curiosity, 110 Cyberbullying, 30 D Damaged or defective self, memories of, 161, 173–177 Danger, fear in face of, 59, 183 DBT. See Dialectical behavior therapy “Dead from the neck down,” 111 Defective self in core memories, 173–177 Defensive anger, 239, 242–244 Defensive emotion, 61, 63, 191, 192 Defensiveness, 102 Degree of Resolution Scale, 134–135, 249, 256, 270, 288, 303 Deliberate suppression, of internal experience, 192 Depression defined, 263 EFTT view of, 24 for emotional abuse survivors, 30–31 maternal, 27 problematic sadness in, 263–264 secondary emotions with, 61–62 self-critical, 208, 219–225 shallow memories with, 164 shame and, 208, 219 working with, 276–277 yoga therapy for clients with, 307, 308, 311, 314 Desensitization, 37, 128 Desires, establishing, 48 Detached narratives, 110, 111 Detachment, 35, 73, 290 Detail level, in memory work, 178 Development, trauma during, 17, 30–31. See also Childhood trauma Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), 16, 18, 22–24, 30, 37 Diagnostic and Statistical Manual of Mental Disorders, fourth edition-text revision (DSM-IV-TR), 18, 22, 23 Dialectical behavior therapy (DBT), 182, 209, 239, 308



Index 357

Dialectical tension between parts of self, 231 Differentiation of feelings/emotions, 53, 141, 241, 250, 262 of intentions, 6, 317 of negative messages, 199 of self-critical statements, 221 Directives to clients, 48, 52, 223 Disappointment, 286, 287 Discovery, fear of, 89 Discovery-oriented approach, 44, 70 Disgust, 16, 208–209, 212, 219, 243 Disorganized attachment, 155 Disrespect, anger at perceived, 248 Dissociation, 140–141, 173, 178–179, 190 Dissociative identity disorder, 179 Distancing, 86, 162, 287, 310 Distractions, 114–115, 264 Distress. See also Global distress assessing current level of, 96 empathic responding to reduce, 81 during IC procedure, 144 information on managing, 83 interventions to contain/reduce, 101, 262–263 nonresponsiveness to, 101 sadness and, 261 Domestic violence, 17, 28, 297, 311 Dominant self, 196–201 Downregulating breath work, 315, 316 Downregulation of emotion for anger, 247 body-based interventions for, 325–326 as change process, 64, 67, 69 compassionate self-soothing for, 228 yoga therapy for, 312 Dream rescripting, 160 Dropout rate, 145 DSM-5. See Diagnostic and Statistical Manual of Mental Disorders, 5th edition DSM-IV-TR. See Diagnostic and Statistical Manual of Mental Disorders, fourth edition-text revision E Early phase of EFTT treatment (phase 1) body-based interventions in, 323–326 client disclosure in, 158–159 crying during, 269 cultivating alliance in, 45–46, 79–102 goals of alliance formation in, 85–94 and guidelines for conducting first three sessions, 94–99 imaginal confrontation procedure in, 125–151 primary task during, 98 promoting experiencing in, 103–124 sequential model of emotional change and, 74–75

EE. See Evocative exploration EFT. See Emotion-focused therapy EFTT. See Emotion-focused therapy for trauma EFTT treatment model. See Emotionfocused therapy for trauma treatment model Ego development, 106–107 Elaboration empathic responding to invite, 51, 81 in healthy anger expression, 242 and memory reconsolidation, 154 in structured focusing procedure, 117–118 Elliott, R., 43 Embarrassment, 211, 213 Embodied trauma rationale, 324 EMDR. See Eye movement desensitization and reprocessing Emotion(s). See also specific types admitting to/labeling vs. experiencing, 181–182 and cognitive goals, 56 in compassionate self-soothing, 228 distinguishing between types of, 58–62, 183–186, 209–212, 240–243, 260–264 explicit teaching about, 88–89 focusing on, 87, 101 intensification of. See Intensification and memory, 56–57 misunderstandings/unrealistic beliefs about, 89 overcontrol of, 28–29, 89, 192–205, 241, 314 providing information on, 83 role of, in adaptive functioning, 56–57 role of, in EFT, 55 shifts in, over EFTT phases, 73–74 underregulation of, 28, 89, 186–187 unstoried, 93 Emotional abuse, 19, 20, 30–31, 89, 169 Emotional arousal. See also Emotional intensity in adaptive anger intervention, 251–252 with anger, 239–240, 242, 244 and capacity for experiencing, 105 as change process, 64–67 in evocative exploration, 145, 147–148 for healthy expression of emotions, 242, 262 in imaginal confrontation, 142–143, 145 during memory work, 160, 162, 170 narratives with low level of, 112 with sadness, 262, 268 window of tolerance for, 22, 184, 310 Emotional competence, 27–29, 36–37, 236 Emotional content, of narrative, 110, 111, 155–156 Emotional development, 3

358  Index

Emotional engagement with trauma material, 73 and client change/outcome, 104, 125, 126, 128 compassionate self-soothing and, 229–231 enhancing, 130–132, 159 in evocative exploration, 147 factors related to, 136–137 gradual, 187, 190, 193, 244–245 in imaginal confrontation, 129–137 levels of, 135–136 memory work and, 159, 164–167 process of, 132–137 quality of, 129, 130 in resolution of self-criticism, 224 and shallow memories, 164–167 and therapeutic alliance, 125–126 Emotional experience. See also Awareness of emotional experience (emotion awareness); Experiencing labeling, 51, 81, 105 perceptions of, 36 understanding, 50–51 Emotional expressiveness, 135, 136, 147 Emotional functioning, feedback on, 288 Emotional inhibition, 28–29 Emotional intensity. See also Emotional arousal change processes related to, 65–67 downregulation of, 64, 67, 69 empathy and, 81 during memory work, 170 modulating, 48, 51–52, 81, 170 problematic levels of, 59, 62 in work with shame, 215 Emotional memory, 57 Emotional neglect, 31 Emotional pain, 186, 226, 229, 259, 261, 312. See also Painful emotions Emotional processing, 62–72 assessing difficulties with, 45 defined, 63 experiencing and, 106–107, 110 general model of, 8, 212 IC for clients with difficulties in, 142, 144–145, 151 identifying dominant difficulty with, 93 imagery and enactments for, 39 and memory reconsolidation, 154–155 narratives indicating problems with, 36, 90, 99 reexperiencing tasks for, 159–160 sequential model of, 68, 72–75 of trauma memories, 6, 37–38 Emotional reaction, IC to evoke, 139–141 Emotional repertoire, limited, 191 Emotional transformation, 6–7 as change process, 64, 70–72, 212–213 client difficulties with, 231–233

compassionate self-soothing for, 225–231 experiencing for, 113, 124 goals for, 212–213 identifying difficulties with, 93 intervention for transforming shame, 218–225 memory work for, 170 in middle phase of EFTT, 74 of secondary anger, 246 yoga therapy for, 308, 313 Emotion awareness. See Awareness of emotional experience Emotion awareness training, 50, 87–89, 144 Emotion coaching beginning, 87–89 with body-based interventions, 324 for clients with history of dissociation, 179 in context of moment-by-moment process, 121–122 to deepen experiencing, 111 empathic responding in, 50 during IC procedure, 144 by parents, 27–28, 36 to reduce fear and anxiety, 191 for survivors of childhood neglect, 169–170 Emotion dysregulation, 136–137, 155, 241, 247 Emotion-focused therapy (EFT), 35 adaptive anger expression in, 240 alliance development in EFTT vs., 85 allowing emotional pain in, 193 bad feelings vs. emotional pain in, 185–186 bottom-up processing in, 200 case conceptualization in, 91 change processes in, 64–72 for couples, 26, 210, 238 deepening experiencing in, 108, 109, 113 for depression, 264, 276 developments in, 5–6 EFTT in context of, 296–297 emotional transformation in, 6–7 experiencing in, 103, 106 forgiveness in, 237 future of, 297 general model of, 5–6, 8, 42–44, 187 intentions in, 312 marker-driven interventions in, 39–40 memory tasks in, 159 mindfulness in, 107 role of emotion in, 55 self-criticism interventions, 225 theory of healthy human functioning, 35–36 on trauma exposure, 310 and trauma research, 296 types of emotion in, 58–62



Index 359

Emotion-focused therapy for trauma (EFTT), 33–54. See also specific techniques and components acceptance of internal experience in, 187 addressing effects of trauma with, 32 anger’s role in, 239, 240 anxiety in, 182–183 avoidance of internal experience in, 182–183 change processes in, 6–8, 37–38, 62–75 client suitability for, 6, 42 for clients with history of childhood abuse, 33–35 defined, 4–5 definition of experiencing in, 105 depression and anxiety disorders in, 24 development of, 33 distinguishing features of, 6–7, 38–42 emotional processing in, 64 emotion theory underlying, 56–62 experiencing in, 105–106 fear in, 182–183 forgiveness in, 237–238 and general model of EFT, 8, 42–44 guilt in, 208–209 as integrative approach, 7–8 intervention principles, 47–49 memory work in, 159–160 past, present, and future perspectives on, 297 primary tasks of, 44–47, 49–54 procedures in, 49–54 relationship tasks in, 80 research context for, 296–297 resolution in, 236–238 shame in, 208–209 theoretical foundations of, 35–38, 296–297 theory of change in, 37–38 treatment model, 44–54 yoga therapy over course of, 323–331 Emotion-focused therapy for trauma (EFTT) treatment model, 44–54. See also specific phases cultivating the alliance in, 45–46 empathic responding in, 49–52 experiential focusing and two-chair enactments in, 54 guidelines for conducting first three sessions, 94–99 imaginal confrontation in, 52 intervention principles in, 47–49 memory work and reexperiencing procedure, 52–53 reducing fear, avoidance, and shame in, 46 resolving trauma and attachment injuries in, 46–47 and sequential model of emotional processing, 73–75

Emotion regulation. See also Downregulation of emotion of anger, 244, 247 beginning to address difficulties with, 89 client capacity for, 42, 67 deficits in emotional competence related to, 27 distractions for clients with difficulties related to, 114 EFTT for clients with poor, 35 empathic responding to improve, 39, 50–51 experiencing as foundation for, 123–124 during IC procedure, 132, 144 identifying difficulties with, 93 during memory work, 162 mindfulness for, 107 modeling of, 50 for overwhelming feelings, 187–188 to promote sadness expression, 269 self-soothing for, 225 in sequential model of processing, 73 underregulation of emotion, 28, 89, 186–187 yoga therapy and EFTT for, 306–307, 312 Emotion schemes, 57–58 for case conceptualization, 91–93 core, 54, 91–93, 159, 164–165, 178 depressive, 264 experiencing to activate, 104 and experiential memory, 105 identifying, 91–93 imagined other and activation of, 139 memory work to activate, 47, 158–160 for primary maladaptive shame, 210 self-related problems and, 25 Emotion socialization, 27–28, 36, 50 Emotion structures. See Emotion schemes Emotion theory, 7, 56–62, 210 Empathic attunement, 38–39, 49–50, 82, 87 Empathic conjecture, 122–123 Empathic exploration, 65, 91, 123 Empathic responding, 6 addressing avoidance with, 192 addressing catastrophic expectations with, 204–205 addressing emotion regulation difficulties with, 89 and awareness of internal changes, 284 cultivating alliance with, 45, 80–81 and development of emotional competence, 28 in EFTT treatment model, 49–52 for emotional transformation, 70 in emotion awareness training, 88 in evocative exploration, 148 in initial sessions, 96–99

360  Index

in memory tasks, 162, 165, 167 and ownership of painful experience, 188 promoting experiencing with, 122–123 promoting sadness with, 267, 268 reliance on, 38–39 in resolution of self-criticism, 223 in structured focusing procedure, 115–117 validation vs., 81 Empathy, 43. See also Evocative empathy attachment theory on, 25 and compassionate self-soothing, 227 compassion vs., 80 functions of, 80–81 for imagined other, 47, 250, 255, 272, 291 in therapeutic relationship, 37, 79 Empirical support for EFTT, 41, 297 for emotion taxonomy, 58 for imaginal confrontation procedure, 127 for integrative model of change, 72 Empowerment in adaptive anger intervention, 254 body-based interventions for, 318–319, 326–327 evocative empathy for, 52 with yoga therapy, 313, 317 Empty-chair procedure, 5, 41, 125. See also Imaginal confrontation (IC) Empty storytelling, 93, 191 Enactments in adaptive anger intervention, 251, 254–255 client difficulties with, 151 in EFTT, 39 facilitating, in imaginal confrontation, 141–142 for letting go, 290–291 modulating emotional intensity with, 48 promoting sadness with, 268 for resolution of intrapersonal conflict, 200 Encoding of trauma memories, 22 Encouragement, 84–85, 267 Enmeshment, 254–255 Entitlement to unmet needs evocative responses promoting, 52 experiencing and, 122 in imaginal confrontation procedure, 53, 143, 270 and resolution of interpersonal trauma, 134, 135, 252, 254 in sequential model of emotional change, 75 shame and, 212, 222 in structured focusing procedure, 118

Epigenetics, 26–27, 296 Episodic memories access to, 164 activating emotion schemes with, 158 imaginal confrontation and, 53, 139–140, 150 memory work with, 47, 162 in work with shame, 215 Equanimity, 310, 315 Europe, 19 Evocative empathy, 52, 81 as basic intervention principle, 48 and experiencing, 112, 122 in IC procedure, 144 in memory work, 131, 160, 177 in structured focusing procedure, 118 Evocative exploration (EE), 8, 34 after resolving intrapersonal conflict, 201 after self-criticism intervention, 222 as alternative to imaginal confrontation, 145–149 in EFTT treatment model, 53 emotional arousal and outcome of, 240 empirical support for, 41 guidelines for conducting, 146–148 in memory work, 161, 163 to reduce fear, avoidance, and shame, 46 switching between IC and, 140, 144, 146, 148–149 before termination, 280–283 Exaggeration, 199–200, 221 Exhale, lengthening, 316 Existential meaning, 309–310, 323 Expectations catastrophic, 61, 196, 200, 204–205 clarifying, 83 realistic, 85, 121, 146, 286 Experiencing, 43, 55, 103–124 in adaptive anger intervention, 253 admitting to/labeling emotions vs., 181–182 body-based interventions to deepen, 326–328, 331 capacity for, 109–110, 119 changes in internal processes, 284–285 client difficulties with, 120–124 compassionate self-soothing, 226, 229 deepening, 53, 109–113 defined, 105–107 in EFTT vs. other approaches, 105–106 features of, 104–105 grounding for, 313 high to highest level of, 113 in imaginal confrontation, 139 low to moderate level of, 107–108, 110–111, 120–121 measurement of, 107–108 moderate to high level of, 108, 112–113 outcome research on, 108–109



Index 361

in resolution of self-criticism, 215, 221, 224 in resolution through sadness or grief, 265–266, 268 structured focusing procedure to deepen, 114–120 symbolization to promote, 189 yoga therapy and EFTT to deepen, 307 Experiencing self, 196–201 Experiential avoidance. See Avoidance of internal experience Experiential focusing, 46, 54, 114–120 Experiential memory, 127 accessing, 39, 104–105 in EE procedure, 146 and emotion schemes, 105 encouraging adaptive anger with, 251 in IC procedure, 141–142, 146 Experiential storytelling, 112–113 Experiential therapy, 7, 35, 39, 42–43, 67–68, 297 Expert stance, of therapist, 101, 110 Exploration. See also Evocative exploration of cognitions, 245–246 of experience, 116–117, 119–120, 123 of meaning, 242, 248, 307 of trauma memories, 127, 312 Exploratory stance, of therapist, 101, 232 Exploring phase (model of allowing emotional pain), 194 Exposure gradual, 101, 187, 213 Exposure, trauma disclosure as, 98 Exposure-based procedures, 4, 16 activating emotion structures with, 57 emotional processing in, 63–64 experiencing in, 106 imaginal confrontation vs. other, 125, 127–128 promoting experiencing in, 104 refusal to participate in/resistance to, 145 Expression and exploration stage (IC procedure), 142–143 Expressiveness, emotional, 135, 136, 147 External detail, in memory work, 165 Externally-oriented narratives, 110–111, 121, 122, 191, 229–230 External resources of clients, 90, 96, 97 External situations, catastrophic expectations about, 204–205 Eye movement desensitization and reprocessing (EMDR), 67, 106, 157 F Facial communication, of shame, 210 Facilitative stance, 110 Failure, fear of, 89 False memories, 160

False self, 209 Fear adaptive, 183 of anger, 239 asking about and addressing, 89 change processes and goals for addressing, 186–189 client difficulties with addressing, 231–233 depression secondary to, 276 of discovery, 89 distinguishing between types of, 183–186 EFTT treatment model for reducing, 46 in EFTT vs. other approaches, 182–183 emotional transformation of, 70, 71 emotion structures centered on, 57 and experiential avoidance, 181 exposure-based interventions for, 64 in face of danger, 59, 183 of failure, 89 interventions for managing, 189–192 of lack of importance, 89 maladaptive, 207 in middle phase of EFTT, 74–75 of negative evaluation, 30, 50, 81, 82, 89, 216–217 of painful emotions, 84, 89 primary maladaptive, 60, 91, 184 problematic, 184–185 PTSD and, 16 reexperiencing memories of, 158 and sadness, 262 as secondary emotion, 61 of termination, 292 working with, in IC procedure, 46, 141 yoga therapy to counter, 313 Fear response, 21, 22, 36 Feedback, 84, 287–289 Foa, E., 157 Focusing. See Structured focusing procedure Foerster, F. S., 134 Forgetting, 82 Forgiveness and adaptive anger, 239, 255–256 in EFTT, 237–238 as issue in early stage, 92 pseudoresolution and, 286, 287 and resolution of trauma, 134, 236, 255–256, 283 self-, 177, 218 strategies promoting, 280–281 Forward fold, standing, 320 Fragmentation, 262 Fragment of memory, activating and exploring, 54, 159, 162, 163, 170 Freund, R. R., 128 Functioning, assessing level of, 96 Fundamental attribution error, 24 Fyvie, C., 16

362  Index

G Garuda mudra, 319, 321 Gaze, in yoga therapy, 317 Gender differences, in childhood maltreatment, 19 Gendlin, E. T., 114 General emotion-focused theory of functioning, 35–36 Generalizability, 42, 72 General model of change, 185, 186, 238 General model of emotional processing, 8, 212 General model of emotion-focused therapy, 5–6, 8, 42–44, 187 General model of resolving intrapersonal conflict, 196–201 Generic memories, 131 George, C., 155 Gestalt therapy, 39, 115, 125, 183 Global distress behavioral self-soothing to reduce, 227 for clients with history of complex trauma, 73 complex maladaptive emotions and, 185 crying related to sadness vs., 261 differentiating adaptive emotions from, 99 dosage of IC and, 126–127 in early phase of EFTT, 74 model for resolving, 68, 134 sadness secondary to, 263 as secondary emotional response, 61 Goals for addressing experiential avoidance, 186–189 for addressing fear, 186–189 for alliance formation, 85–94 case conceptualization for development of, 94 collaboration on, 45 for initial dialogue of IC, 138 for memory work, 158–160 for resolution through sadness and grief, 264–266 for resolving intrapersonal conflict, 196–197 reviewing, 280, 281 for transforming shame, 212–213 treatment, 95–96 for yoga therapy with EFTT, 310–314 Goddess pose, 327 Goodbye, saying, 272, 282, 290 Good-enough parenting, 225 Gottman, J. M., 27–28, 88 Gradual engagement, 187, 190, 193, 244–245 Gradual exposure, 101, 187, 213 Greenberg, L. S., 5, 8, 34, 41, 56, 58, 134

Grief avoidance of, 59 change processes and goals for working with, 264–266 complicated, 258–260, 263 expressing, in imaginal confrontation, 141 as focus of therapy sessions, 266 intervention for self-related losses and depression, 274–277 interventions for promoting, 268–274 resolution of interpersonal trauma through, 257–277 traumatic, 258–260, 264–265 Grounding body-based interventions for, 317–318, 325–326 managing anxiety and fear with, 189–190 during memory work, 178–179 with yoga therapy, 313, 317 Growth, 286, 289 Guided meditation, 309, 324 Guilt, 3, 211 compassionate self-soothing to transform, 225–231 in EFTT vs. other approaches, 208–209 importance of addressing, 207 markers of, 219 during memory work, 163 with PTSD, 24 rationale for work on, 220 as secondary emotion, 61 self-criticism related to, 222–225 survivor, 211 H Habituation processes, 126, 157 “Hand on heart” gesture, 316 Happiness, desire for, 329–330 Harm, risk of, 6 Harrington, S., 102 Harvey, A. G., 38 Health, focus on, 38 Healthy expression of emotion anger, 240–242, 245, 252–253 sadness, 262, 269–270 Healthy protest, 200–201, 220–222, 224 Herman, J. L., 157 Higher power, belief in, 323 Holistic approach to yoga therapy, 308 Holocaust survivors, 27 Holowaty, K. A. M., 109, 182, 240 Honeymoon phase, for refugees, 276 Hope, 84–85, 143, 277 Hopelessness, 188, 261 Hostility, 219, 232–233 “hot” processes, 69, 149, 187, 189, 225, 231, 248, 324



Index 363

Hridaya mudra, 319 Human trafficking, 19, 297 Humiliation, 208, 213, 227 Hurt, 191, 248 Hyperarousal, 23, 157 Hypervigilance, 23, 191, 212 I IC. See Imaginal confrontation (IC) Idealized imagined other, 272–273 “if–then” approach, 39–40 “I” language, 130–131, 147, 242, 252 Imagery, 39, 48, 160, 320–321 Imaginal confrontation (IC), 8, 33–34, 125–151. See also Initial dialogue of imaginal confrontation after resolving intrapersonal conflict, 201 after self-criticism intervention, 222, 225 anger intensification in, 248 client difficulties with, 149–151 compassionate self-soothing during, 226 cultivating alliance with, 45 in EFTT treatment model, 47, 52 emotional arousal and outcome of, 240 for emotional transformation, 71 empirical support for, 41 ending, 143 enhancing engagement in, 130–132 evocative exploration vs., 53, 145–149 exploring painful emotions in, 194 initiating and structuring, 139, 149–150 managing anxiety and fear with, 189, 190 in memory work, 161 other exposure-based procedures vs., 127–128 with perpetrators, 126–130 process of engagement in, 132–137 to promote primary adaptive anger, 248–256 rationale for using, 138, 139, 149 to reduce fear, avoidance, and shame, 46 relationship development in, 143–145 for resolution through sadness/grief, 266 resolving interpersonal trauma with, 132–134 self-interruption in context of, 201–204 shifting from memory work to, 163 similarities to resolving intrapersonal conflicts, 199 switching between evocative exploration and, 140, 144, 146, 148–149 before termination, 280–283 and therapeutic alliance, 125–126 therapist operations in, 138–143 Imaginal exposure, 160 Imaginal reentry task, 159, 160 Imaginary dialogues, clients resistant to, 54

Imagined other “bad object” view of, 92, 132, 236, 291 client difficulties with enacting, 151 compassion for, 272–274 differentiating feelings toward, 141 emotional reaction in response to, 139–141 empathy for, 47, 250, 255, 272, 291 enactment/vivid experiential memory of, 141–142 ending contact with, 256 expressing anger toward, 251–253 external detail to elicit, 147 idealized, 272–273 new view of relationship with, 255–256 perceptions of, 92, 146, 148, 236, 250, 251, 253–254, 270, 288 selection of, 138 structural problems preventing dialogue with, 149–150 supporting new view of, 255–256, 272–274 supportive reactions from, 266 Immune system, 29, 36 Importance, fear of lack of, 89 Inadequacy, 216–217 Incoherent narratives, 154, 155, 164, 167–168 Incomplete memories, 154 Index of change, 282–283 Information, providing, 82–85, 97–98 Inhibition, emotional, 28–29 Initial dialogue of imaginal confrontation client difficulties with, 149–151 evoking emotional reaction in, 139–141 importance of, 129–130 initiating and structuring, 139 intervention principles for, 131–132 relationship development in, 143–145 selecting imagined other for, 138 Insecure attachment, 29, 190, 191 Insecurity, 81–82, 184–185 Insight, 69–70 Insight-oriented therapies, 65, 105 Intensive short-term dynamic psychotherapy, 239 Instructor role, 100 Instrumental emotion, 62, 63, 243, 246 Integrating phase (model of allowing emotional pain), 194–195 Integrative approach, 7–8, 296 Integrative model of change, 72 Intellectual narratives, 110, 111, 122, 307 Intensification of anger, 239, 248, 252 for clients with history of self-harm behaviors, 232 in intervention for self-critical processes, 221, 224

364  Index

to resolve intrapersonal conflict, 199–200, 203 techniques for achieving, 143 therapist responses to achieve, 170 Intentions, 48, 309, 312, 315, 321, 331 Internal experience acceptance of, 187 client feedback on, 289 directing attention to, 109, 131–132, 140, 165 discrepancy between outward presentation and, 165–167 expressing, in IC procedure, 131–132 lack of clarity about, 94 symbolizing, in yoga therapy, 314–315 in work with shame, 213, 216 Internalization, 226, 290 Internalized critic, 220–225 Internalized self-invalidation, 173–175 Internal object relations, 40–41 Internal processes awareness of changes in, 284–285 encouraging exploration of, 84 Internal resources of clients, 90, 96, 97, 194 Internal representation, 58 Internal working models, 57 International Statistical Classification of Diseases and Related Health Problems, 11th edition, 24 Interpersonal approaches, experiencing in, 105, 108–109 Interpersonal connectedness, 52–53, 81, 86, 236, 274–275, 315 Interpersonal history, taking, 96 Interpersonal problems body-based interventions to address, 330–331 dosage of IC and, 126, 127 IC for past trauma vs. current, 127–129 resolving, in late phase of EFTT, 75 as trauma symptoms, 26–27 Interpersonal style of client, 102 Interpersonal trauma CPTSD associated with, 208 during development, 30–31. See also Childhood maltreatment emotion-focused therapy for depression vs., 5 by perpetrators known to the victim, 17 PTSD symptom severity with, 20 resolution of. See Resolution of inter­ personal trauma yoga therapy for women with history of, 311 Interpretations, process observations vs., 84 Interrupting clients, 121 Intimacy needs, 292 Intimate partner violence, 19–20, 243 Intrapersonal conflict, 196–201, 231

Intrusive symptoms of PTSD, 22, 28, 170, 172–173 Involvement, in therapy process, 135, 136 Irritability, with PTSD, 23 Isolation, 81, 188, 274 J Janoff-Bulman, R., 23 Justice, 255 K Kapota mudra, 319 Khayyat-Abuaita, U., 73–74 Kindness, 263, 314 L Late phase of EFTT treatment (phase 3) body-based interventions in, 330–331 identifying, 235 imaginal confrontation procedure in, 142–143, 249–256 resolution through adaptive anger, 235–256 resolution through sadness and grief, 257–277 resolving trauma and attachment injuries in, 46–47 sequential model of emotional change and, 75 termination of therapy in, 47, 279–294 Laurent, C., 49 Left brain, 104 Letting go in adaptive anger intervention, 255 allowing emotional pain for, 265 body-based interventions to promote, 319–320 client difficulties with, 290–291 forgiveness and, 237 resolution and, 236, 271–272 in yoga therapy, 314 Levels of Engagement Scale, 132, 135–136 Limited exposure trauma, 16–17 Limited gains, from therapy, 285–287 Linehan, M., 82, 83 Line-in-the-sand, for relationship, 128 Linguistic memory, 104–105 Lion’s breath, 316 Loneliness, 274–277 Longing, expressing, 270 Loss(es) accepting, 188, 258, 265 awareness of, 265 depression at, 208 grieving, 258, 268–274 self-exploration related to, 265–266



Index 365

self-related, 274–276 termination of therapy as, 293 verbal symbolization of pain of, 268 Love, grieving lack of, 271 Loving-kindness meditation, 323, 329–330 M Main, Mary, 155 Maintaining gains, after termination, 281–282 Maintenance responses, 170 Major depressive disorder, 164 Maladaptive anger, 242, 246–248 Maladaptive anxiety, 185 Maladaptive beliefs, 169–170, 196–197 Maladaptive emotions awareness of, 54, 65–67 change process with, 66–67 changing, as mini-outcome, 39 complex, 6, 28, 61–63, 185–186 emotional pain vs., 185–186 emotion awareness training focusing on, 88 global distress with underlying, 61 modifying, with adaptive emotions, 7–8 necessity of evoking, 232 primary, 60 with PTSD, 24 reducing experience of, 181–205 reflection on, 69 yoga therapy for shifting out of, 312 Maladaptive guilt, 211 Maladaptive sadness, 262–263 Maladaptive sense of self, 162–163 Maladaptive shame, 215–225 compassion to counteract, 314 maladaptive fear and, 207 primary, 60, 91, 156, 210, 218–225, 275 reducing secondary, 215–217 transforming primary, 218–225 types of, 210–211 Maladaptive fear, 207 Malcolm, W., 134 Marital distress, 26 Marker-driven intervention, 39–40, 83 Maternal depression, 27 Matter-of-fact approach to therapy, 101 Meaning bridging to broader, 118 emotional, 307 existential, 309–310, 323 exploring, 49, 70, 111, 112 loss as disruption in, 259 meditation practices focusing on, 322 of nonverbal/paraverbal expressions, 214 processing, 256 spiritual, 309–310, 323

symbolizing, 48, 109, 174, 246, 268 in yoga therapy, 309–310 Meaning construction in emotional processing of memories, 37–38 for emotion regulation, 247 empathic responding for, 51 experiencing and, 43, 113 focusing principles for, 119–120 in memory work, 156, 169–170 for recovery from trauma, 104–105 reflection on emotion for, 70 in resolution through sadness or grief, 265–266 with trauma disclosure, 98 in trauma therapy, 103 Meditation, 309, 322–323 Memory(-ies) activating/exploring fragments of, 54, 159, 162, 163, 170 concrete, 131, 150, 165 defective/damaged self, 173–177 and emotion, 56–57 encoding traumatic experiences in, 21, 22 evocation of, 47, 48, 60, 164–165, 215, 247 shallow, 164–170 warded off, 161, 170–173 Memory gaps, 23, 160–161 Memory reconsolidation, 85, 154–155 Memory work, 5, 9, 153–179 approaches to, 156–158 body-based intervention to enhance, 329 compassionate self-soothing during, 226 considerations and cautions with, 177–179 disclosure vs., 158–159 in EFTT, 159–160 in EFTT treatment model, 52–53 goals and process of, 158–160 imaginal confrontation vs., 127 markers for, 161 with memories involving defective/ damaged sense of self, 173–177 practice guidelines for, 160–163 as reprocessing task, 43 for resolving shame and self-criticism, 219 sense of self as target of, 153 with shallow memories, 164–170 steps in, 161–163 theoretical underpinnings of, 154–156 with warded off memories, 170–173 Men, EFTT for treatment of, 42 Mental health issues assessment of, 96 childhood adversity and, 20–21 childhood maltreatment and, 31, 295 yoga therapy for, 305 Mentalization, 106–107, 182 Merundada mudra, 318 Metaphoric language, 131, 320

366  Index

Meta-awareness, 214 Middle phase of EFTT treatment (phase 2) body-based interventions in, 326–330 imaginal confrontation procedure in, 142 memory work in, 153–179 reducing fear, anxiety, and avoidance in, 46, 181–205 resolving intrapersonal conflict in, 198 sequential model of emotional change and, 74–75 transformation of guilt, shame, and self-blame in, 46, 207–233 Military veterans, 17, 28, 239, 311 Mind–body connection, 310–311 Mindful breathing, 322 Mindfulness, 107, 306–307 Mindfulness-based cognitive therapy, 264 Mindfulness-based stress reduction, 310–311 Minimization, 174–175, 192, 195, 196, 220 Mini-outcomes of EFT, 39–40 Moment-by-moment experience, 105, 121–122 Motivation, 95–96, 237–238 Mountain pose, 317 Mourning, models of, 259 Mudras, 316–321 Mutual feedback, at termination, 287–289

Needy child, self as, 228 Negative emotions, urgency of, 56 Negative evaluation, fear of, 30, 50, 81–82, 89, 216–217 Negative message in intervention for self-critical processes, 221 for resolution of intrapersonal conflict, 199–200, 202 Negative self-evaluations, 219 Negative self-statements, 216 Negative states, shifting out of, 312 Negotiation between aspects of self, 222 Nervous system dysregulation, 22, 310 Neurobiological effects of trauma, 310 Neuroimaging studies, 296 Neutral psychoanalytic stance, 86, 100 New information, in final IC or EE dialogue, 281, 282 Nieuwenhuis, J. A., 41 Niyamas, 309 Nonassertiveness, 137 Nonattachment, 188 Nonverbal behavior, 214, 269 Normalization of experience, 51, 82, 294 Numbing and numbness, 23, 307, 314, 321–322 Nurturing, 227, 228, 267

N

O

Narcissism, 291 Narcissistic personality disorder, 137 Narcissistic rage, 208, 219 Narrative approaches to therapy, 106, 259 Narrative disclosure therapy, 157–158 Narrative-emotion subtypes, 93 Narrative memory problems, 5 Narrative processes, 9, 25–26, 38. See also Storytelling Narratives for emotional processing, 36 emotions expressed during, 73–74 externally-oriented, 110–111, 121, 122, 191, 229–230 incoherent, 154, 155, 164, 167–168 intellectual, 110, 111, 122, 307 overgeneral, 111, 155, 164, 167–168 quality of, 110–113, 155–156, 288–289 references to internal resources in, 90 reprocessing tasks related to, 43–44 Narrative style, 93, 97 National Comorbidity Study, 24 Needs. See also Unmet needs associated with losses, 265 attending/responding to, 228 establishing, 48 expressing, 200–201, 221–222 feedback on recognition of, 288

Objective clinical observer stance, 100 Object relations, 57, 58, 128, 253 O’Kearney, R., 90 Operant conditioning, 21–22 Opposites of experience, 321–322 Outcome research on adaptive anger expression, 239–240 on evocative exploration, 145 on experiencing, 108–109 on imaginal confrontation, 125–126, 135, 145 on therapeutic alliance, 102 Overcontrol of emotion, 28–29, 89, 192–205, 241, 314 Overgeneral narratives, 111, 155, 164, 167–168 Overly directive therapist style, 100–101 Overwhelming feelings, regulation of, 187–188 Ownership of experience, 130–131, 139, 144, 188, 214–215, 252 P Painful emotions. See also Emotional pain allowing, 193–194, 265 anxiety secondary to, 185 approaching, 193



Index 367

avoidance of, 59–60, 63, 193–196 case example, 195–196 downregulation of, 67, 69 experiencing, 182 exploring, 194 fear about dredging up, 84, 89 during imaginal confrontation, 126 integrating, 194–195 reluctance to activate, 232 therapist’s comfort with, 298 Painful experiences, allowing and owning, 188 Paivio, S. C., 5, 9, 34, 41, 49, 53, 109, 119, 126, 130, 182, 240, 307 Paradoxical sadness, 263 Paraverbal expressions, 214 Parenting difficulties, unresolved trauma and, 26–27 Parents, prohibitions on anger against, 245 Pascual-Leone, A., 8, 45, 72, 108–109 Passive-aggressive behavior, 291 Past trauma, current problems and, 92, 128–129 Patience, 121 Peluso, P. R., 128 Performance anxiety, 122, 137, 150, 208 Perpetrators. See also imagined other adaptive shame for, 210 current interpersonal problems with, 128–129 enmeshment with, 254–255 forgiveness for, 237–238 healthy anger directed at, 241 holding, accountable, 283 identifying, 85–86 imaginal confrontation procedure with, 126–130 ongoing interactions/relationships with, 258, 273–274 resolution and perception of, 134, 143, 283–284 self-interrupted feelings about, 201 as stimulus for dissociation, 190 unfinished business with, 94 Perrott, K., 90 Perseveration, 82 Persistence, 121 Personal agency, 54 body-based interventions to promote, 328–329 integration of painful emotions for, 195 process observations and awareness of, 189 in resolution of interpersonal trauma, 272 in resolution of intrapersonal conflict, 199, 200 in resolution of self-criticism, 223 in work with shame, 214–215 yoga therapy to promote, 313, 315

Personality pathology, 102, 137, 208, 290–291 Personal memories, 165 Personal standards, violating, 217–218 Person-centered focus, 103–104 Phase 1 of EFTT. See Early phase of EFTT treatment Phase 2 of EFTT. See Middle phase of EFTT treatment Phase 3 of EFTT. See Late phase of EFTT treatment Physical abuse, 19, 30, 238 Physical pain, recalling experience of, 178 Polaris, 19 Polyvagal theory, 310 Positive affect, 87 Positive change, client awareness of, 284–285 Positive effects of soothing, 226, 229 Positive emotions, 56, 60 Positive experiences, 308, 312–314, 328–329 Positive self-evaluations, 222 Posttraumatic growth, 7, 236–237, 260 Posttraumatic stress disorder (PTSD), 42 destructive anger with, 257 development of, 21–22 diagnostic criteria for, 16, 18, 22–23 dysfunctional beliefs in, 183 EFTT for individuals with, 5 fear, anxiety, and avoidance in, 182 fear in, 184 guilt, shame, and self-blame in, 208 intrusive symptoms of, 172–173 and marital distress, 26 narrative quality and symptoms of, 155 prevalence of, 20–21 primary maladaptive emotion in, 60, 184, 242 resolution through sadness or grief with, 264 secondary emotions with, 61–63 shallow memories with, 164 single incident/limited exposure trauma and, 16–17 symptoms of, 22–24, 29 theory of dysfunction in, 36 as trauma and stress-related disorder, 37 underregulation of emotion with, 28 yoga nidra as treatment for, 311 Power, M. J., 16 Powerlessness, 140, 254, 267, 271, 313 Power postures, 318–319, 326–327 Prayer hands, 316 Predialogue stage (IC procedure), 138–139, 149–150 Present-centered awareness to address fear, anxiety, and avoidance with, 182

368  Index

to address shame, 214 in memory work, 162, 173–174 to promote sadness, 267 in yoga therapy, 309, 313, 315, 317 Present difficulties, past trauma and, 92, 128–129 Primary adaptive anger, 241, 248–256 Primary adaptive emotions, 59–60 accessing, as mini-outcome, 39 accessing, for emotional transformation, 70, 71 in middle and late phases of EFTT, 75 reflection on, 69 secondary emotions covering, 191–192 Primary adaptive fear, 276 Primary adaptive sadness, 268–269, 276 Primary adaptive shame, 210, 217–218, 276 Primary emotions adaptive vs. maladaptive, 59–60, 63 awareness and arousal of, 65–66 helping clients allow, 192–205 Primary maladaptive anger, 242 Primary maladaptive emotion, 60, 63 counterconditioning fear as, 153–154 and maladaptive emotion scheme, 91 in middle phase of EFTT, 74–75 reflection on, 69 transformation of, 70–72 transforming shame as, 218–225 Primary maladaptive fear, 184 Primary maladaptive sadness, 262–263 Primary maladaptive shame, 60, 91, 156, 210, 218–225, 275 Process-directive intervention, 39–40 Process observations addressing avoidance with, 192 building awareness of personal agency with, 189 for clients with experiencing difficulties, 121–122 in imaginal confrontation, 132, 142 for productive alliance, 84 in therapist feedback to client, 288–289 in work with shame, 215 Progressive muscle relaxation, 114 Projections, 219–220 Prolonged exposure, 157, 159 Prompts, memory task, 162 Protection, yoga postures promoting, 317 Protective factors, for vicarious traumatization, 18 Pseudoresolution, 271, 286–287 Psychedelics, 23, 295, 297 Psychodynamic approach, 7 anger in, 239 experiencing in, 105, 108–109 memory work in, 157–158 reducing avoidance in, 182 view of shame in, 209

Psychoeducation, 192, 216 Psychological contact, 53, 135, 136, 147, 269 Psychological separation, 236, 237 PTSD. See Posttraumatic stress disorder Purging emotion, 65 Q Questions directing client attention with, 48 during memory task, 162 promoting experiencing with, 122–123 R Radical acceptance, 182 Ralston, M., 147, 240 Rational narratives, 307 Reactivation of intrusive symptoms, 172–173 Reactivity symptoms of PTSD, 22, 28 Realistic expectations, 85, 121, 146, 286 Reassurance, 81, 84–85, 170, 224 Reconciliation, 283, 286, 287 Recovery, in EFTT, 128 Reexperiencing procedures compassionate self-soothing during, 226 in EFTT, 37, 52–53 evocative exploration as, 53 exploration of memory in, 164–165 managing anxiety and fear with, 189 in memory work, 155, 156–157 modulation of emotional experience in, 51 present-centered awareness during, 173–174 promoting sadness expression with, 269 reducing fear, avoidance, and shame with, 46 sense of self as target of, 153 Reexperiencing symptoms, 36 Reflection on emotion, 188 as change process, 64, 69–70 directing client attention with, 47–48 identifying difficulties with, 93 Reflective functioning, 106 Reflective levels of experiencing, 112–113 Reflective memories, 165 Refocusing client attention, 213 Refugee trauma, 17–19 depression and, 276–277 EFTT for treatment of, 44, 297 primary maladaptive fear with, 184 primary maladaptive sadness with, 262–263 PTSD and, 21 relational focus in work with survivors of, 86



Index 369

Rehearsal of in-session emotional development (e.g., sequence), 74 Rejecting anger, 74, 287, 314 Rejection, shame and, 208 Relapse, 286–287, 293, 294 Relational approach to therapy, 7, 105 Relational focus, establishing, 85–86 Relational psychodynamic therapy, 37, 40, 63 Relational tasks, 43 Relational trauma, 134, 236–237, 297 Relationship issues, 4, 289 Relaxation, 114–115, 313, 316 Releasing postures, 314 Reliving procedures, 127 Reparenting processes, 86 Repressed memories, 54, 160–161 Reprocessing tasks, 43–44, 50, 127 Resignation, 271, 286, 287 Resilience, 7, 38, 90, 310 Resistance to imaginal confrontation, 54, 139, 141, 145–147 to letting go, 290–291 to loving-kindness meditation, 329–330 Resolution of internalized self-criticism, 219–225 case example, 222–225 eliciting healthy protests and needs, 221–222 ending session involving, 224–225 intensifying and exaggerating negative message, 221 self-understanding and new interactions in, 222 specifying and differentiating self-critical statements, 221 structuring dialogue for, 220 switching to IC, EE, or self-soothing after, 222 Resolution of interpersonal trauma body-based interventions for, 330–331 bringing closure to, 280–282 client difficulties with, 289–291 disappointment with degree of, 286 in EFTT treatment model, 34–35, 38, 46–47 with EFTT vs. other exposure-based procedures, 127 feedback on degree of, 288 forgiveness and, 92 with IC, 132–134 impact of initial dialogue of IC on, 130 individual variations in, 283–284 measuring progress through, 134–135 process of, 238 relapse after, 293–294 theory and research on, 236–238 through adaptive anger, 235–256 through sadness and grief, 248, 257–277

Resolution of intrapersonal conflict, 196–201 Resolution of relational trauma, 236–237 Resolution stage (IC procedure), 143 Respect, 248, 255 Retraumatization, risk of, 146, 221 Return to therapy, discussing, 294 Revenge fantasies, 252 Revictimization, 16, 85–86, 183 Right brain, 27, 104 Risk factors, for vicarious traumatization, 17–18 Rogerian approach to therapy, 44 Rogers, C. R., 35, 103–104, 209 Role definition, for productive alliance, 83–84 Role-playing, 254–255 Ruptures in alliance, 99–102 S Sadness, 3. See also Adaptive sadness about termination, 292–293 as basic emotion, 260–261 change processes and goals for working with, 264–266 decision to seek resolution through anger vs., 250–251 difficulties letting go of, 290 distinguishing between types of, 260–264 EFTT interventions for, 6 expression of, 36, 141 healthy expression of, 262, 269–270 in imaginal confrontation, 141 as instrumental emotion, 62 intervention for self-related losses and depression, 274–277 primary, 261–263 problematic, 262–264 promoting, 268–274 PTSD and, 16 research on, 257 resolution of interpersonal trauma through, 237, 248, 257–277 secondary, 263 at separation/loss, 59 “Safe place” visualization, 320 Safety body-based interventions for, 318 to cultivate alliance, 45, 79, 85, 102 to work with sadness/grief, 258, 266 yoga therapy to provide, 313, 317 “Same old story” storytelling, 93 Sankalpa, 309, 312, 321 Sareen, J., 18, 20–21 Savasana, 319 Schore, A., 27 Secondary anger, 242–243, 245–248

370  Index

Secondary emotions, 60–63, 69, 191–192 Secondary sadness, 263 Secondary shame, 61, 211, 215–217 Secure attachment, 27, 45, 51, 86–87, 100–101, 143–144 Selective reflections, for gradual engagement, 244 Self. See also Sense of self adaptive sadness directed at, 262 anger, contempt, and disgust directed at, 212 contact between parts of, 231 as defective or damaged, 173–177 exploring perceptions of, 53 extreme hostility toward, 232–233 feedback on perceptions of, 288 negotiation between aspects of, 222 supporting new view of, 254–255, 271–272 tracking perceptions of, 253–254, 270 understanding, in terms of wants and needs, 254 as vulnerable needy child, 228 Self-awareness, 50–51, 69–70 Self-blame, 3 compassionate self-soothing to transform, 225–231 with CPTSD, 208 evocative exploration to counteract, 148 importance of addressing, 207 markers of, 94 with PTSD, 24, 208 self-critical statements about, 221 self-soothing interventions for, 163 sense of self organized around, 185 working with, 34, 141 Self-care, 17, 225 Self-compassion, 60, 260, 329–330 Self-condemnation, 217–218 Self-confidence, 289 Self-consciousness, 210, 214 Self-critical depression, 208, 219–225 Self-critical statements, differentiation of, 221 Self-criticism, 5–6. See also Intrapersonal conflict addressing, 9 emotional abuse and, 30 and maladaptive shame, 60 markers of, 94 nonverbal expression of, 214 resolving, 39–40, 197, 219–225 shame and, 61 yoga therapy to counter, 314 Self-destructive behaviors, 44, 217–218 Self-directed anger, 212 Self-esteem, 208, 236, 289 Self-evaluation, negative, 91–93 Self-exploration, 194, 265–266

Self-forgiveness, 177, 218 Self-harm behaviors, 42, 232, 306–307 Self-indulgence, 227, 323 Self-injurious behaviors (SIBs), 29, 44 Self-interruptive processes, 5–6. See also Intrapersonal conflict case examples of, 195–196, 201–204 and catastrophic expectations, 204–205 as conscious avoidance, 192 in context of imaginal confrontation, 201–204 reducing, 195–196 during structured focusing procedure, 117, 118 tasks for resolving, 197 Self-invalidation, internalized, 173–175 Self-loathing, 176–177 Self-narrative, 188 Self-organization, 24, 26, 58, 92 Self-protective resources, 160, 163, 174–175, 228 Self-related losses, 274–277 Self-related problems addressing, in middle phase of EFTT, 74–75 body-based interventions to address, 326–330 EFTT treatment model to reduce, 46 experiential focusing and two-chair enactments to reduce, 54 explorations of, at high levels of experiencing, 112, 113 and IC participation, 141, 142 resolution of interpersonal trauma and, 132, 289–290 as trauma symptoms, 25–26 Self-soothing after allowing painful emotions, 195–196 after self-criticism intervention, 222 compassionate, 225–231 downregulation of emotion and, 67 in memory work, 161, 176 and reducing experiential avoidance, 190 in resolution of self-criticism, 220 in resolution through sadness/grief, 267 shifting from memory work to, 163 in yoga therapy, 313 Self-understanding, 201, 222 Sense of self. See also Core sense of self in adaptive sadness intervention, 267–268 fragile, 291 integrating painful emotions into, 194–195 and maladaptive emotion scheme, 91–92 strengthening, 75, 267–268 as target of reexperiencing/memory work, 153 Sensorimotor psychotherapy, 157



Index 371

Sensory experiencing, of trauma memories, 22 Separation, psychological, 236, 237 Sequential model of emotional processing, 68, 72–75 Sequential replaying of events (sequential reexperiencing), 54, 159–162, 168, 171–172, 175–176 Serenity Prayer, 188 SEU. See Systematic evocative unfolding Sexual abuse, 17, 163, 178, 208–209. See also Child sexual abuse Sexual dysfunction, 30 Sexual predation, 30 Shallow memories, 164–170 Shame, 3. See also Maladaptive shame about violating personal standards, 217–218 adaptive, 210, 217–218 challenges in working with, 207 change processes and goals to transform, 212–213 child sexual abuse and, 30 client difficulties with transforming, 231–233 compassionate self-soothing to transform, 225–231, 227 compassion to counteract, 314 defined, 210 distinguishing between types of, 209–212 in EFTT vs. other approaches, 34, 208–209 emotional transformation of, 70–72 emotions related to, 211 imaginal confrontation to work with, 141 importance of addressing, 207 memory work to reduce, 9 in middle phase of EFTT, 74 principles relevant to working with, 213–215 with PTSD, 24 reducing, in EFTT treatment model, 46 reducing secondary, 215–217 reexperiencing memories of, 158 and sadness, 262 secondary, 61, 211, 215–217 transforming primary maladaptive, 218–225 Shame–anxiety, 87, 208, 211–212, 327–329 Shattered assumptions, with trauma, 23 “Should” statements, 221 Shunning, 210 Silence, as indicator of difficulty, 123–124 Single incident trauma, 16–17 Skills training, 189–190, 209, 225–226, 239, 324 Snippets of memory, 157

Social anxiety EFTT procedures to treat, 50, 51 from emotional abuse, 169 in emotion-focused approach, 5 imaginal confrontation and, 137 and shame-based sense of self, 219 shame underlying, 208, 211–212, 216–217 and trauma in development, 30 Social developmental theory, 29 Social support network, building, 292 Socratic style, 100 Somatic experiences, in depressive emotion scheme, 264 Somatic-focused therapies, 295, 297 Sorrow, 265, 269 Sounds for embodied experience, 314–315 Specific memories, 131, 165 Spiritual meaning, 309–310, 323 Stabilization phase, in therapy, 136, 157 Standards, 201, 217–218, 309 Standing forward fold, 320 Standing power postures, 318–319 Storytelling. See also narrative processes with competing plotlines, 192 empty, 93, 191 experiential, 112–113 with “same old story,” 93 with shallow memories, 167–168 superficial, 93 transitional, 156 Strength-promoting yoga postures, 317 Strengths, client, 90, 96, 97, 289 Structured focusing procedure, 114–120 Attending to bodily felt experience, 115 bridging to life, 118–119 elaborating and accepting, 117–118 exploring experience, 116–117 finding the right words, 115–116 integrating, in therapy process, 119–120 relaxation, calming, and freeing mind of distractions, 114–115 Structured meditation, 322 Subjective internal experience attending to. See Experiencing defined, 103 expression of, 131–132 Subjective units of distress (SUDS) ratings, 135 Substance abuse, 44 Successive approximations approach, 244–245, 252, 315 “Sufi grind” movement, 318 Suicidal ideation, 20 Superficial storytelling, 93 Superhero stance, 319 Support in adaptive sadness intervention, 267 for grieving, 258–260 for interventions related to shame, 213

372  Index

for new perceptions of other, 272–274 for new perceptions of self, 271–272 to promote primary adaptive anger, 254–255 for resolving self-criticism, 220 sadness and seeking, 261 Suppression of depressed mood, 264 of internal experience, 192 of sadness, 261, 268 Surrender, 314, 319–320 Survivor guilt, 211 “Switching chairs,” in IC procedure, 141–142 Symptom management, after relapse, 293 Systematic evocative unfolding (SEU), 159, 160, 168 T Taillieu, T. L., 20, 31 Talk therapy, body-based interventions with, 305, 306 Task collaboration, 138–139, 161, 197, 199 Task markers, identifying, 94 Tasks of therapy, defined, 98 Taylor, G. J., 29 Teletherapy, 146 Termination of therapy, 279–294 body-based interventions for clients at, 331 bridging to the future at, 294 client difficulties with, 291–293 completion and consolidation of changes for, 280–285 and difficulties with resolution process, 289–291 duration of phase, 279 in EFTT treatment model, 47 limited change at, 285–287 premature, 293 sequential model of emotional processing at, 75 sharing mutual feedback at, 287–289 Therapeutic alliance, 79–102 client difficulties with, 99–102 in early phase of treatment, 45–46 and engagement in IC procedure, 125–126, 130 and experiencing, 109 feedback on, 289 goals of alliance formation, 85–94 and guidelines for first three sessions, 94–99 principles for developing, 80–85 Therapeutic environment, 110, 266, 267 Therapeutic gains, 281–282, 285 Therapeutic relationship, 4 in EFTT, 6, 37 functions of, 79

and initial IC procedure, 143–145 meeting attachment needs with, 86 and relationship tasks in EFTT, 80 support for grieving in, 258–260 Therapeutic weeping, 268 Therapist(s) client need for interaction with, 150–151 compassionate soothing by, 226 defining role of, 83–84 expert stance of, 101, 110 exploratory stance of, 101, 232 mutual feedback between client and, 287–289 operations by, in imaginal confrontation, 138–143, 250–256, 269–274 reluctance to activated painful feelings by, 232 yoga therapy practice for, 315 Third-wave approaches, 107 Thoughts, inhibition of, 29 Time, for expressing sadness, 266 Tip-of-the-tongue phenomenon, 116 Top-down processing, 39, 200, 225 Torture, 18 Transference, 80, 292 Transgenerational transmission of trauma, 26–27, 296 Transitional storytelling, 156 Trauma, 3. See also specific types defined, 16 during development, 30–31 effects of, 21–32 EFTT theory of dysfunction specific to, 36–37 emotional memory related to, 57 emotions in situations of, 262 establishing focus on, 85–86, 147 exposure to, 18–19 impact of therapists’ deep engagement with, 297–298 neurobiological effects of, 310 and prevalence of PTSD, 20–21 shattered assumptions with, 23 theoretical perspectives on anger and, 238–240 tolerance for exploration of, 83 transgenerational transmission of, 26–27, 296 Trauma disclosure, 87, 98–99, 158–159, 170–172 Trauma-focused psychological services, demand for, 32 Trauma memories disclosure of, in EFTT vs. EFT, 44 emergence of, in IC procedure, 153 emotional processing of, 6, 37–38 exposure-based procedures for evoking, 127



Index 373

imaginal confrontation to evoke, 131 nature of, 154 reconsolidation of, 154–155 Trauma narratives of clients with unresolved/unprocessed trauma, 104 emotional content of, 110, 111, 155–156 indicators of emotional processing difficulties in, 90 quality of productive, 155–156 retelling of, in memory work, 155 subtypes of, 156 Trauma reexperiencing, 9, 158, 159–160. See also Memory work Trauma resilience, 7, 38 Trauma-sensitive yoga programs, 311 Trauma symptoms, 21–31 addressing, 31–32 in complex traumatic stress disorder, 24–25 development of, 21–22 dosage of IC and, 126–127 emotional competence deficits, 27–29 emotion and, 87 engagement quality and severity of, 136–137 interpersonal problems, 26–27 in posttraumatic stress disorder, 22–24 secondary shame about, 216 self-related problems, 25–26 with trauma during development, 30–31 Trauma theory, 21, 36 Trauma therapies. See also specific types allowing and accepting feelings in, 182 changing dysfunctional beliefs in, 183 client suitability for, 6 emotion as target in, 55 experiencing in, 105 impact of emotional engagement for practitioners of, 297–298 meaning construction in, 103 memory work in, 153 Traumatic event(s) as focus of therapy, 42 prevalence of exposure to, 18–19 types of, 16–18 Traumatic grief, 258–260, 264–265 Trust, 45, 51–52, 81–82, 102, 221, 317 Two-chair dialogues, 9. See also specific procedures to accept self-related losses, 274 body-based intervention to enhance, 327–330 conflict/contact between parts of self in, 231 in EFTT treatment model, 43, 54 evocative empathy in, 52 to explore continuing relationship with perpetrator, 273–274

extreme hostility against self in, 232–233 to reduce fear, avoidance, and shame, 46, 183 to reduce self-critical processes, 153, 168, 214, 215, 219–225 to resolve intrapersonal conflict, 197–204 task markers for, 94 yoga therapy to support, 312, 322 Two-stepped empathic responses, 99 U Uncertainty, 48, 82 Unconditional acceptance, 83 Unconditional positive regard, 35 Unconscious avoidance, 191 Underregulation of emotion, 28, 89, 186–187 Unfinished business, 5, 7–8, 29, 94, 125 UNHCR (United Nations High Commissioner for Refugees), 18 United Nations High Commissioner for Refugees (UNHCR), 18 Unmet needs. See also Entitlement to unmet needs in adaptive sadness and grief intervention, 259 compassionate self-soothing and, 227 core, 92–93 expressing, 53 imaginal confrontation to address, 143, 270 in maladaptive emotion scheme, 92–93 promoting expression of, 253 self-related losses and, 275–276 Unresolved trauma activation of maladaptive sense of self with, 175 chronic contempt as indicator of, 212 feelings of victimization/powerlessness with, 267 narrative quality and, 155–156 and parenting difficulties, 26–27 Unspeakable events, 157, 170–172 Unstoried emotion, 93 Upregulating breath work, 315, 316 Urgency, of negative emotions, 56 V Vague memories, 154 Vague storytelling, 111, 164, 167–168 Validation, 51 of adaptive anger, 247 in adaptive sadness intervention, 267 in compassionate self-soothing, 228, 231 to cultivate alliance, 48, 81–82, 87 during memory work, 161 to promote experiencing, 123

374  Index

and resolving intrapersonal conflict, 202 during trauma disclosure, 98–99 of vulnerability, 171 in work with shame, 214, 216 in yoga therapy, 317 Value, of experiencing, 110 Values, 111, 201, 309, 312 Vehicular accidents, 16 Venting emotion, 65 Verbal contract, to extend treatment, 293 Verbal processing, 22, 48, 51 Verbal symbolization in experiencing, 105 in experiential focusing, 54 in initial dialogue of IC, 132 of pain of loss, 268 to reduce anxiety, 188–189 in reflection on emotion, 69 in structured focusing procedure, 115–116 Veterans, military, 17, 28, 239, 311 Vicarious traumatization, 17–18, 298 Victimization, 140, 208, 211, 254, 267 Vietnam War, 17 Violation, 59, 241, 262, 267 Violence, 28, 30–31, 238–239 Visualization, 314–315, 320–321, 328–329 Vitality, increasing sense of, 314 Vulnerable, core sense of self as, 184–185, 228 Vulnerable feelings affirming, 48, 123, 162, 171, 213 client’s access to, 93 difficulties expressing, 270 in EFTT, 34 in evocative exploration, 140 expressing, 34, 140 with expression of unmet needs, 253 in interventions for shame, 213 in memory work, 162, 165–167, 171 orienting away from hostility and toward, 232–233 promoting experiencing by affirming, 123

sadness and grief as, 266 transforming secondary anger into, 246 W Wants, establishing, 48 Warded off memories, 161, 170–173 Warmth, interpersonal, 86–87 War-related trauma, 17, 27, 239 WAI (Working Alliance Inventory), 79, 301 Welcoming-promoting yoga postures, 317 Window of tolerance, 22, 184, 310 Winnicott, D. W., 209 Wishfulness, 290–291 Withdrawal, 123–124, 189, 214, 261. See also Avoidance of internal experience (experiential avoidance) Withdrawal ruptures, 99, 100 Withholding therapist style, 100 Wonder Woman stance, 319 Working Alliance Inventory (WAI), 79, 301 World Health Organization, 24 Worth, conditions of, 209 Worthlessness, 71–72, 216 Y Yamas, 309 Yeryomenko, N., 108–109 Yoga classes, yoga therapy vs., 308 Yoga nidra, 311, 321, 322 Yoga therapy, 297, 305–331 for awareness of emotional experience, 307 background literature on, 310–311 defined, 308–310 effectiveness of, 310–311 for emotional transformation, 308 for emotion regulation, 306–307 for experiencing, 307 intervention principles for, 314–315 over course of EFTT, 323–331 practices and tools in, 315–323 processes and goals of, 311–314 requirements for providers of, 306

ABOUT THE AUTHORS

Sandra C. Paivio, PhD, CPsych, maintains a private practice in Toronto, Ontario, Canada, provides clinical training at the York University Psychology Clinic, and is Professor Emeritus in the Psychology department at the University of Windsor. She is one of the developers of emotion-focused therapy, particularly applied to complex trauma (EFTT), and has conducted clinical trials evaluating the efficacy and processes of change in EFTT. She has authored numerous publications on trauma and psychotherapy. These include Working With Emotions in Psychotherapy (with Leslie S. Greenberg), Emotion-Focused Therapy for Complex Trauma, First Edition (with Antonio Pascual-Leone), and Narrative Processes in Emotion-Focused Therapy for Trauma (with Lynne E. Angus). Dr. Paivio is featured in several DVDs published by the American Psychological Association. She is a certified trainer (International Society for Emotion Focused Therapy) in emotion-focused therapy and has presented numerous clinical training workshops internationally on EFTT. Dr. Paivio received a Lifetime Achievement Award from the Trauma Section of the Canadian Psychological Association (2014) for her contributions to research and training in treatment for complex trauma. Antonio Pascual-Leone, PhD, CPsych, is a professor in psychology at the University of Windsor, Canada, where he is director of the Emotion Change Lab, and he is honorary professor of psychiatry at the University of Lausanne, Switzerland. He has published seminal contributions to the theory and research of emotion-focused therapy and is regarded as a world expert in emotional processing. He coauthored Emotion-Focused Therapy for Complex Trauma, First Edition (with Sandra C. Paivio) and is writing a transtheoretical book on changing emotion (American Psychological Association). His work is recognized by career awards  375

376  About the Authors

from international societies (Society for Exploration of Psychotherapy Integration, 2009; Society for Psychotherapy Research, 2014), as well as distinguished publication awards from associations in the United States and Germany (American Psychological Association, 2010; Society for the Research and Treatment of Personality Disorders, 2016). Dr. Pascual-Leone is a certified trainer (International Society for Emotion Focused Therapy), has given workshops in a dozen countries, and has received awards for teaching and mentorship (2016, 2018) that recognize leadership in education and his innovation in teaching psychotherapy skills. His TEDx talk on resolving relational trauma has been viewed over 3 million times. He runs a private practice seeing individuals and couples.